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HEALTH SCIENCES 
LIBRARY 



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Digitized by the Internet Archive 
in 2014 



https://archive.org/details/newyorkmedicaljo1131unse 



W YORK MEDICAL JOURNAL 

INCORPORATING THE 

PHILADELPHIA MEDICAL JOURNAL 

AND THE 

MEDICAL NEWS 



SEMIMONTHLY REVIEW OF MEDICINE 

AND SURGERY 



VOLUME cxin. 

JANUARY TO JUNE, 1921. INCLUSIVE 



NEW YORK 
A. R. ELLIOTT PUBLISHING CO 
1921 



COPYRIGHT. 1921, BY A. R. ELLIOTT PUBLISHING COMPANY. 



LIST OF CONTRIBUTORS TO VOLUME CXIII. 

Those whose names are marked with an asterisk have contributed editorial articles. 



Aaron, Charles D., M. D., Detroit, 
Mich. 

ACATSTON, S. A., M. D. 

Apfel, H., M. D., Brooklyn. 

♦Arrowsmith, Hubert, M. D., F. A. 
C. S., Brooklyn, N. Y. 

AsHBY, Winifred, B. S., M. S., Roches- 
ter, Minn. 

AsNis, Eugene J., M. D., Philadelphia. 
Atwell, Wayne J., Buffalo, N. Y. 

Babcock, W. Wayne, M. D., F. A. 

C. S.. Philadelphia. 
Bailey, John H., M. D., Brooklyn, 

N. Y. 

Ballenger, Edgar G., M. D.. F. A. C. S., 
Atlanta, Ga. 

Barker, Lewellys F., M. D., Baltimore. 

Barker, Walter C.. M. D., Philadelphia. 

Barnes. George Edward, B. A., M. D., 
Herkimer, N. Y. 

Behrend, Moses, M. D., Philadelphia. 

Besse, p. M., M. D., Geneva, Switzer- 
land. 

BicK, H., M. D. 

Blair, Thomas S.. M. D.. Harrisburg, 
Pa. 

Blau, Arthur I., M. D. 

Blumgarten, a. S., M. D., F. A. C. P. 

Boas, Ernest P., M. D. 

♦Bolduan. Charles F., M. D., Wash- 
ington, D. C. 

Bram, Israel, M. D., Philadelphia. 

Brav, Aaron. M. D.. Philadelphia. 

Briggs, L. Vernon, M. D., Boston, 
Alass. 

*Brink, Louise, A. B. 

Broadwin, I. T., M. D. 

Buchanan, J. Arthur, M. D., Roches- 
ter, Minn. 

Buckley, Albert C, Philadelphia. 

Bulkley, L. Duncan, M. D. 

Bullard, E. a.. M. D., F. a. C. S. 

Burns, Frank, M. D., Cincinnati, Ohio. 

Burns, Joseph P., M. D., Philadelphia. 

Putsch, J. L., M. D., Ph. D., Roches- 
ter, Minn. 

Butts, Donald C. A., M. D., Philadel- 
phia. 

Callison, James G., M. D. 
Carmody, Thomas Edward, M. D., Den- 
ver, Colo. 
Cecil, Russell L., M. D. 
Clark, L. Pierce, M. D. 
*Clouti ng, Ch,\rles a., AI. D., London. 
Cohen, Harry, M. D. 
Cohen, Samuel, M. D., Philadelphia. 



Coon, C. E., M. D., F. A. C. S., Syra- 
cuse, N. Y. 

Crane, Claude G., ■ M. D., Brooklyn, 
N. Y. 

Crile, George W., M. D., F. A. C. S., 
Cleveland, Ohio. 

*Cumston, Charles Greene, M. D., 
Geneva, Switzerland. 

Cyriax, Edgar F., M. D. (Edin.), Lon- 
don. 

Deaver, John B., M. D., Philadelphia. 
De Brun' Harry Schultz, M. D. 
Dewess, a. M., Philadelphia. 
♦Donnelly, William Henry, M. D., 

Brooklyn, N. Y. 
Drueck, Charles J., M. D., Chicago. 

Eidelsberg, Joseph, M. D. 
Einhorn, Max, M. D. 
Eising, Eugene H., A. M., M. D. 
Elder, Omar F., M. D., Atlanta, Ga. 
*Elliott, George, M. D., Toronto. 
Ellison, Everett M., A. M., M. D., 

Washington, D. C. 
Ezickson, William J., A. B., M. D., 

Philadelphia. 

Faught, Francis Ashley, M. D., Phila- 
delphia. 

Finklepearl, Henry, M. D 

*Foster, Matthias Lanckton, M. D., 
New Rochelle, N. Y, 

Fowler, Robert H„ M. D. 

Frankel, Bernard, M. D. 

Frantz, Morris H., M. D. 

Friedman, G. A., M. D. 

Friedman, Joseph, M. D., Brooklyn. 

Friedman, Joseph H., M. D. 

Freudenthal, Wolff, M. D. 

Galland, Walter L, A. B., M. D. 

Gardner, James A., M. D., F. A. C. S., 
Buffalo, N. Y. 

Garretson, William V. P., M. D. 

Geyser, Albert C, M. D. 

Gies, William J., M. D., D. Sc. 

Gilbride, John J., A. M., M. D., Phila- 
delphia. 

GoETSCH, Emil, M. D., F. A. C. S., 

Brooklyn. 
Goldman, Harry', M. D. 
Goldstein, Hyman L, M. D., Camden, 

N. J, 

Gordon, Alfred, M. D., Philadelphia. 
Gordon, Murray B., M. D., F. A. C. P., 
Brooklyn. 

Goutzait, p., AI. D., Geneva. Switzer- 
land. 



Grai), Herman, M. D. 
Graham-Mulhall, Sara, M. D. 
Greenfield, Arthur D. 
Greenfield, Samuel D., M. D., Brook- 
lyn. 

Haines, Wilbur H., B. S., M. D., Phila- 
delphia. 

Hallock, Daviu H., a. M., M. D., 

Southampton, N. Y. 
Hamilton, James A., Ph. D. 
Hammer, A. Wiese, M. D., Philadelphia. 
High MAN, Walter James, M. D. 
Hirshfeld, Samuel, M. D. 
Hodskins, Morgan B., M. D., Palmer, 

Mass. 

Hoxie, George Howard, A. M., M. D., 

Kansas City, Mo. 
Huhner, Max, M. D. 
Husik, J. A., A. B.. M. D., Brooklyn. 
Hyslop, George H., M. D. 

Iglauer, Samuel, B. S., M. D., Cincin- 
nati, Ohio. 
Illoway, H., M. D. 
Imperatori. Charles J., M. D. 

Jackson, Chevalier, M. D., Philadel- 
phia. 

Jacoby, Adolph, M. D. 
*Jelliffe, Smith Ely, A. M., M. D., 
Ph. D. 

Kahn, Max, M. D. 
Kaplan, David M., M. D. 
Keller, Henry, M. D. 
*Kellogg, Elenore. 
Kelly, Howard A., M. D., Baltimore. 
Kempf, Edward J., M. D. 
Kennedy, J. W., M. D., F. A. C. S. 
*Kerbv, Ernest F., M. D. 
*KiNG, Douglas, M. D. 
*Knopf, S. Adolphus, M. D. 
Knowlton, Frank P., AI. D., Syracuse. 
N. Y. 

KouiNDjY, Pierre, AI. D., Paris, France. 

Landsman, Arthur A., AI. D. 
Lapenta, Vincent Anthony, M. D.. 

Indianapolis, Ind. 
Lazarus, David, M. D. 
Levy, Louis Henry, AI. S-, AI. D., New 

Haven, Conn. 
Levy, Moise D., AI. D.. Galveston, 

Texas. 

Levyn, LeSter, AI. D., Buffalo, N. Y. 
Lewinski-Corwin. E. H., Ph. D. 
*LiEB, Charles, M. D. 
Limerick, O. Victor, AI. D. 
LiNTZ, Joseph, A. M., AI. D. 



LirsiiLTZ, Uknjamin, M. D., I'liiladcl- 
phia. 

LissER, Hans, M. D., San Francisco. 
LowsLEV, Oswald Swinney, A. B., 

M. D.. F. A. C. S. 
LuTTiNGER, Paul, M. D. 
Lydston, G. Frank, M. D., Chicago. 
Lynch, Robert C, M. D., New Orleans, 

La. 

McCaskey, Donald, M. D. 

McNuLTY, John J., M. D. 

Maiiukkn, Russell F., M. D. 

Marshall, C. J., Philadelphia. 

Martin, Sergeant Price, M. L)., Buf- 
falo, N. Y. 

Meding, C. B., M. D. 

Melman, Ralph J., M. D., Philadelphia 

Melville, Stanley, M. D., London. 

Menninger, Karl A., M. S., M. D., 
Topeka, Kansas. 

Meyer, William H., M. D. 

Miller, Edwin B., M. D., Philadelphia. 

Miller, George L, M. D., Brooklyn. 

Miller, Joseph W., M. D. 

Mills, H. Brooker, M. D., F. A. C. P., 
Philadelphia. 

Minton, Henry M., M. D., Philadelphia. 

Morley, W. H., M. D., Pontiac, Mich. 

Morris, M. Ford, Jr., M. D., Atlanta. 
Ga. 

Mosher, Eliza M., M. D., Brooklyn, 
N. Y. 

Murphy, John W., A. M., M. D., Cin- 
cinnati, Ohio. 

Mutch, Jane, B. A., London. 

Mutch, N., M. A., M. D., F. R. C. P., 
London. 

Neuhof, Harold, M. D. 
Neumann, William, M.^D., Brooklyn. 
Niles, Walter L., M. D. 
Norman, N. Philip, M. D. 
Northrop, Herbert L., M. D., F. A. 
C. S., Philadelphia. . 

O'Day, J. Christopher, M. D., F. A. 

C. S., Honolulu, Hawaii. 
Osborne, Oliver T., M. D., New Haven, 

Conn. 

Owen, Hubley R., M. D., Philadelphia. 

Pancoast, Henry K., M. D., Philadel- 
phia. 



Patterson, Klli:n J., M. D., F. A. C. S., 

Pittsburgh, Pa. 
Pkeiffer, William, M. D., F. A. C. S., 

Brooklyn. 
♦I'liELPs, Edith B. 
Porter, William Henry, M. D. 
Pottenger, F. M., M. D., Monrovia, Cal. 
Prentice, Alfred C. M. D. 
Pritchard, H. B., M. D., Syracuse, 

N. Y. 

Pyle, Walter L., M. D., Philadelphia. 

Reed, Charles A. L., M. D., Cincinnati, 
Ohio. 

Reede,- Edward Hiram, M. D., Washing- 
ton, D. C. 

Renaud, George L., M. D., Detroit, 
Mich. 

Riddell, Hon. William Renwick, 

LL. D., Toronto, Canada. 
Ridpath, Robert F., M. D., Philadelphia. 
Roberts, John B., M. D., Philadelphia. 
Rodman, Harry, M. D. 
♦Rogers, James F., M. D., New Haven, 

Conn. 

Rose, Robert Hugh, M. D. 

Rosenberger, Randle C, M. D., Phila- 
delphia. 

Rosenbluth, M., M. D. 

Rosenheck, Charles. M. D. 

Rout, Ettie A. (Mrs. Hornibrook), 
London, England. 

Rubenstone, a. L, M. D., Philadelphia. 

*Rucker, W. C, M. D., United States 
Public Health Service, Canal Zone. 

RuTZ, Anthony A., M. D., Brooklyn, 
N. Y. 

*Sajous. Charles E. de M., LL. D., 
M. D., Sc. D.; Philadelphia. 

♦Sajous. Louis T. de M., B. S.. M. D., 
Philadelphia. 

Sanders, A. S., M. D. 

Saphir, J. F., M. D. 

Satterthwaite, Thomas E., M. D. 

*Scarlett, Rufus B., M. D., Trenton, 
N. J. 

ScHROEDER, THEODORE, CoS Cob, CouU. 

Sc hwartz, Louis H., A. B., M. D. 
Shapiro, Isidor F., M. D. 
Sheehan, J. Eastman, M. D. 
Shuman, John W., M. D.. F. A. C P., 
Sioux City, la. 



Shltmway, Edward A., M. D., Phila- 
delphia. 

SiEGEL, Alvin E., M D., Philadelphia. 
Smith, Ethan H., M. D., San Fran- 
cisco. 

SoLis-CoHFX, Myer, a. B., M. D., Phila- 
delphia. 

Spencer, Willi a. m H., M-. D., Philadel- 
phia. 

*STEINBUf;LER, WiLLIAM F. C, M. D. 

Stevens, J. Thompson, M. D., Mont- 

clair, N. J. 
Stivelman, B., M. D., Bedford Hills, 

N. Y. 

Strachstein, a., M. D. 
*Stragnell, Gregory, M. D. 
Strauss, Spencer G., A. B., M. D. 

Takeuchi, Kumpei, M. D., Toyko. 

Taylor, K. P. A., A. B., M. D., Phila- 
delphia. 

Tenner, Arthur S., M. D. 

Thomson, J. Oscar, M. D.. Canton, 
China. 

Tiltox, Benjamin T., M. D. 

Tim me, Walter, M. D. 

TousEY, Sinclair, M. D. 

TuTTLE, Homer, M. D., Ithaca, N. Y. 

Van Hook, Weller, A. B., M. D., Chi- 
cago. 

*Vedin, Augusta, M. D. 

*Warburton, Gladys Bagot. 
*Waterson, Davina. 
Watson, W. R., M. D., Philadelphia. 
Wells, Walter A., M. D., Washington, 
D. C. 

Wheelon, Homer, M. D., St. Louis, Mo. 
*Whitford, William, Chicago. 
♦Williamson, Jefferson. 
Wishart, D. J. Gibb, M. D., Toronto. 

Canada. 
Witherbee, W. D., M. D. 

*W0LBARST, AbR. L., M. D. 

Wright, Jonathan, M. D., Pleisant- 

ville, N. Y. 
WuRTZ, Walter J. M., M. D., Buffalo. 

N. Y. 

Young, Anne, M. D., Dr. P. H., 
D. T. M., University, Alabama. 

ZiGLER, M., M. D. 



New York Medical Journal 

INCORPORATING THE 

Philadelphia Medical Journal the Medical News 

A Weekly Revieiu of Medicine, Established 18Jt3. 

Vol.. CXIII, No. 1. NEW YORK. SATURDAY, JANUARY 1, 1921. Whole No. 2196. 

Original Communications 



OPERATION FOR RENAL CALCULI. 

By Howard A. Kelly, M. D., 
Baltimore, Md. 

Within the past forty years the surgical pro- 
fession has run a gamut of changes in the variety 
of operations for stone in the kidney and the renal 
pelvis. It is my desire here to present what I 
consider to be the simplest and best procedure and 
one which I hope approximates a final solution of 
this important question in the commoner cases. 
Back of the seventies of the last century kidney 
operations were extremely rare, and however excru- 
ciating the pain the patient might suffer in his loin, 
coupled as it might be with hemorrhages and pyuria, 
his treatment was symptomatic and sedative. How 
well I remember the course of just such a case in 
the person of one' of my most intimate boy friends, 
handled throughout its course by the late distin- 
guished surgeon, my professor, D. Hayes Agnew. 
With growing boldness in surgery following G. 
Simon's initiative in his elaborate experimental work 
on the extirpation of the kidney (1872), and with 
the security given by antisepsis, the next step natur- 
ally was the exposure and opening of the kidney, 
often literally like an oyster, from stem to stem, 
hunting for the stone which was too often elusive. 
I had such a case in one of my closest friends. 
He suffered for a long time from hematuria and 
sudden attacks of intense posterior lumbar pain ; 
often when driving his buggy through the streets 
of a distant large city at night, when the pain struck 
him he would double up and fall to the floor until 
it passed. William Osier, who knew him, suggested 
it might only prove to be a focal nephritis, but I felt 
more confident of stone. According to promise I 
opened his kidney from end to end, and found — 
nothing. He recovered from this and was relieved 
of his pains, but he died several years later in a 
uremic convulsion following a surgical operation 
on the axillary glands for a gas bacillus infection 
contracted in an operation on an infected arm. 

Following this came the era of \some more intel- 
ligently determined and directed operations, due 
to the introduction of the waxed tip catheter in the 
nineties, an intelligence soon augmented by the 
gradually perfected x ray diagnosis, which not only 
defined the disease, like the waxed catheter, but also 
located the position, and often the number and size 
of the stones. With this greater precision in diag- 
nosis the incision into the kidney naturally was often 



more limited in its extent, although still appallingly 
extensive, and the damage done was still consider- 
able, and the hemorrhage sometimes threatening. 
Then came an era of pyelotomies for pelvic stones, 
particularly encouraged by an avascular posterior 
incision between the vascular watersheds of the 
kidney, when the cut had to be extended up into 
the kidney, thus lessening the hemorrhage. 

I exclude from consideration massive and ex- 
tensively branching calculi, where there is nothing 
to be done but to excise the kidney, when its func- 
tion is wholly in abeyance, or at most to incise it 
from end to end in the effort to remove the calculus 
without extensive tearing of the tissues. 

My own active personal association with, and 
interest in, this field, has passed through several of 
the stages cited above. Soon after discovering the 
method of direct aerocystoscopic examinations, with 
the pelvis elevated, I waxtipped my bougies and 
so was often able in favorable stone cases to get 
a scratch mark on the wax, and so to make an 
immediate diagnosis at the very first examination, 
of a stone in the ureter or kidney. A great advan- 
tage of this method is that it is carried out on the 
examining table and does not require any prepara- 
tion of the patient, or the delays incident to a 
reference to an x ray expert often in another clinic. 
With due care the wax tip method is both certain 
and satisfactory, and I still use it as a routine, while 
using the x ray also. 

In my effort to save the kidney from injury, I 
then began to resort extensively to pyelotomy, draw- 
ing especial attention to the necessity of preserving 
the fibrous sheath investing the pelvis of the kidney, 
described by Dr. William J. Mayo and myself. 
This sheath also investing ureter and bladder, is of 
particular value in both of these latter situations as 
a binder in closing incised wounds. 

Lastly I worked out the operation which I am 
about to describe ; at first blush an apparent return 
to our former cruder plan of splitting open the 
kidney, but differing toto coelo in being done with 
a full understanding of the exact status of the or- 
gan, as to functional value, site and number of stones 
as well as their size, and with a definite technic 
adapted to the particular case. This procedure is 
accompanied with a minimal and usually insig- 
nificant trauma, as yet with no serious hemorrhage;' 
it is rapid in its execution, and usually avoids any 
urinary leakage, such as was not infrequently under 
older methods. On account of its rapidity and the 



Copyright, 1921, by A. R. 



Elliott Publishing Company. 



2 



KELLY: RENAL CALCULI. 



[New York 
Medical Journal. 





slight damage done, I, am in the habit of calHng 
it at the operating table my "sneaking operation." 
Let me describe it : 

A patient comes with a pyuria or a hematuria, 
or both, and often with a one sided pain. The 
mixed urine is taken by catheter from the bladder, 
and if a woman, the ves- 
ical ends of the ureters 
are palpated carefully 
through the vagina. She 
is then cystoscoped in 
the knee chest posture, 
and the suspicious side 
catheterized with a 
waxed tip catheter 
(Fig. 1 A). The urine 
flowing directly from 
that side is collected in 
a test tube, while the 
urine discharging from 
the other side is collected 
transvesically by an or- 
dinary vesical catheter 
in a test tube. At the 
same time the functions 
of the kidneys are esti- 
mated by examining the 
separated urines and by 
injecting phenolsulphone- 
phthalein. After one or 
two hours, or sometimes 
after a few minutes, if 
the differentiation of 
the urines is sufficiently 
marked to the naked eye, 
the renal catheter is removed and the waxed tip is 
examined with a lens for scratch marks (Fig. IB). 
An X ray picture then taken also shows the calculus 
or calculi either in the renal pelvis or up in one or 
more of the calices (Fig. 2). 



Fig. 1. — A, a ureteral catheter 
from 1 J4 to 2 mm. in diameter 
— the end coated with wax. B, 
the same catheter after it has 
been gouged or scratched by com- 
ing into contact with the stone 
in the pelvis of the kidney. Note 
that the wax covered end is 
sometimes hammered down as 
shown here. 



THE OPERATION. 

The best incision is through the posterior superior 
lumbar triangle. In many cases I pull the tissues 
widely open with my two hands by a blunt dissec- 
tion, thus securing enough room to introduce four 
or five fingers, the whole hand. After breaking 
through Gerota's capsules by simple traction with 
forceps on the perirenal fat it is often possible to 
draw the entire kidney out onto the surface. 
Whether it comes out in this way, or whether it 
has to be detached by gentle manipulations on all 
sides, separating it par- 
ticularly in its upper 
pole, in most cases, it is 
displaced onto the loin 
without the slightest 
damage, and dealt with 
there in the succeeding 
stage. Often, however, 
knowing exactly the 
position of the stone, I 
operate upon the kidney 
in situ, and make a direct opening into its lower 
pole, or again simply free and tilt down the upper 
pole, so as to bring it within reach for the extraction 
of the calculus. In either case, whether treated 
in situ or outside, the operator gently palpates the 
kidney between the thumb and fingers, including 
the renal pelvis, to see whether the stone can be 
felt and located. If it is found it can then be 
thrust up toward the dorsum with the fingers to 
facilitate the enucleation. If it is not so located, 
then with the x ray plate before him as a guide the 
next step is to take a fine needle about six cm. in 
length, fastened in a cork, and to thrust this into 




Fig. 3. — Contour of kidney, 
needle mounted on cork thrust 
into contact with stone, and left 
there. 




Fig. 2. — Shadowgraph of the stone in the pelvis of the left 
kidney under an unusually long last rib. 



Fig. 4. Fig. S. 

Fig. 4.— Spatulate instrument neither blunt nor sharp thrust 
through the dorsum of kidney after making a short incision in its 
capsule, and brought in contact with stone, which in most in- 
stances can be pushed up towards the cortex to meet the in- 
strument. 

Fig. S. — Scissors used occasionally to enlarge the opening when 
necessary. A little blunt tearing in this way as a rule provokes 
no marked hemorrhage. The scissors can be used very well to 
replace the instrument (Fig. 4) entirely. 

the kidney, where it is expected the stone will be 
found. Once the needle touches the stone, it is 
left (Fig. 3) in situ, while a small incision (averag- 
ing about two cm. in length, but varying with the 
size of the stone) is made through the renal cap- 
sule. An instrument is then taken in hand (Fig. 4) 
which is neither blunt nor sharp, and which can be 



January 1. 1921.] 



KELLY: RENAL CALCULI. 



3 



[0 



pressed against the finger without cutting it. This 
is driven through the renal substance down to the 
stone. A narrow pair of forceps (Fig. 6) is then 
inserted and the stone caught and extracted. If 
the removal is clean and clear, and there is only a 
mild infection, I close the wound entirely with one 
or two mattress sutures (Fig. 7) ; as 
^1 the bleeding is usually minimal, a 
single catgut mattress suture may suf- 
fice. The external abdominal wound 
is then closed with a small drain. 
Sometimes it is an advantage, if the 
stone is a little large, to carry the scis- 
sors into the pelvis until the stone is 
touched, and on withdrawing to oi)en 
them a little, thus enlarging the 
opening in a blunt way ( Fig. 5 ) . 
Such a procedure as I have just de- 
tailed is splendidly adapted to a stone 
which is out in one of the calices, and 
not far distant from the cortex. I 
have removed in this way, with almost 
no damage at all, a stone from the 
upper and lower poles of the same 
kidney, first tilting up one end and 
then the other. I also prefer this 
operation for stone in the pelvis of the 
kidney as well, pushing the stone up 
toward the dorsum. 

Case. — Let me illustrate my thesis 
further and dwell on this important 
matter by citing a concrete case, that 
of Mrs. E. M., No. 8911, who came 
to me February 10, 1920, with a diag- 
nosis of left renal calculus, made by 
a skillful consultant and a friend in Buffalo. 
I took an x ray (Fig. 2) as confirmatory of 
the diagnosis, and without detailing the vari- 
ous differentiation tests and preliminary exam- 
inations made, I proceeded with the operation. The 
usual posterior mcision was made through the pos- 
terior superior lumbar triangle, and the kidney 
freed and delivered at the incision. Gentle palpa- 
tion fore and aft showed the presence of the stone 
in the renal pelvis. A fine cambric needle was then 
inserted through the back of the kidney, avoiding 
the vascular lines, and left in situ, touching the 

stone. A little incision 
was made through the 
capsule, and the blunt 
instrument shown (Fig. 
3) pushed through the 
kidney and through the 
renal pelvis until it 
touched the stone, when 
both it and the needle 
were withdrawn; and 
the stone grasped with 
the forceps (Fig. 4) 
and lifted out. One 
mattress suture was 
placed through the kidney near the hilum with a 
blunt flat curved semicircular needle and tied gently, 
just tight enough to control the circulation in the 
limited area near the pelvis. Two catgut sutures 
were then placed in the wound, uniting the capsule 



KiG. 6. — Nar- 
r o «■ forceps 
grasping and 
removing stone. 




Fig. 7. — Sutures placed to 
control the hemorrhage and 
unite the capsule. The outer- 
most suture is often put in just 
above the pelvis of the kidney 
using rather fine catgut; a and 
b close the upper parts of the 
wound and the capsule. 



of the kidney, and the kidney was restored to its 
position back of the peritoneum, and the muscles 
brought together with catgut, a small iodoform 
drain being left in the lower part. Recovery was 
rapid without any leakage, and she left the hospital 
on March 1st. Frecjuently twelve to fourteen days 




Fig. 8. — With the exception of a flat, blunt pointed needle these 
are the few simple instruments used in locating the stone, open- 
ing the dorsum of the kidney, and removing the stone; a, the fine 
needle used to find the exact position of the stone; b, the spatulate 
instrument neither blunt nor sharp which is plunged through into 
the pelvis of the kidney; c, scissors sometimes used to enlarge the 
opening a little; d, the stone forceps used for the removal of the 
calculus when it is somewhat larger; narrow forceps used to extract 
a small calculus. 

are long enough for the convalescence. The sketches 
used in the text were made to illustrate this case. 
I prefer this operation even when the calculus is 
in the pelvis of the kidney and easily accessible, in 
almost all cases. 



Renal Hematuria. — Edward A. Young (Sur- 
gery, Gynecology and Obstetrics, November, 1920) 
concludes that: 1. The cause of renal hematuria 
can be demonstrated in all but a very small propor- 
tion of cases. 2. Kidney bleeding of unknown 
origin has been known to be enough to threaten life 
and require nephrectomy. 3. A horseshoe kidney, 
a slightly movable kidney, a varix of a renal papilla, 
may exist without the possibility of positive pre- 
operative diagnosis. 4. In a few instances the split 
ftmction may show considerable damage on the 
bleeding side and the pyelogram a considerable de- 
viation from the normal, a combination which should 
require exploration ; but these cases are very rare 
and operation as a routine exploratory procedure in 
cases of hematuria of unknown origin is unwise, 
as there is no assurance that it will have any effect 
on the progress of the bleeding. 5. In a fair num- 
ber of these cases a later nephritis has been proved 
to be the cause of trouble. 6. It is reasonable to 
believe that in a majority of these cases there is an 
early unrecognized nephritis or a prenephritic con- 
dition which can be the cause of hematuria, and 
that this condition may go on to a progressive dam- 
age of the kidney. 



4 



TILTON: GALLSTONE DISEASE. 



[New York 
Medical Journal. 



DANGERS TO LIFE ASSOCIATED WITH 
GALLSTONE DISEASE AND 
THEIR PREVENTION. 

By Benjamin T. Tilton, M. D., 
New York. 

Every individual with gallstones encounters cer- 
tain definite dangers of a complication which may 
change what, seems to be a simple, though painful, 
local manifestation into a condition of affairs which 
may prove fatal. This may happen during any 
period of gallstone disease and, in fact, may be the 
first occurrence which demonstrates unmistakably 
to the patient or physician the fact that gallstones 
are present. Indefinite digestive disturbances which 
may be attributed to the stomach may be present 
for many months, when out of a clear sky an acute 
attack of cholecystitis or a sudden jaundice lays the 
patient low. More frequently a patient suffers for 
months or years from intermittent attacks of gall- 
stones before one of these, dangerous emergencies 
arrives. 

There are four chief -dangers that may threaten 
the life of a carrier of gallstones: 1. Acute suppu- 
rative or gangrenous cholecystitis ; 2, cholangitis ; 
3, malignant disease of the gallbladder, and, 4, opera- 
tion in delayed cases. 

Acute suppurative or gangrenous cholecystitis is 
ushered in with excruciating pain in the right hypo- 
chondrium, sometimes a chill, rising temperature, 
and usually vomiting. The pain frequently radi- 
ates to the right shoulder. Examination reveals 
marked abdominal rigidity, a mass caused by the 
distended gallbladder and adherent omentum, a very 
high leucocyte and characteristically high polynu- 
clear count. Jaundice is usually absent, but if 
present may be caused by pressure of enlarged 
glands on the common duct. The diagnosis should 
be easily made. 

Operation should not be delayed in the severer 
types of cases. Sepsis, perforation of the distended 
or gangrenous gallbladder may occur. Simple 
drainage of the gallbladder is the operation of 
choice in the severe cases, especially those that have 
been delayed to the detriment of the patient's gen- 
eral condition. Mortality from this complication of 
gallstones is usually due to delay in operation or 
to the attempt of a too radical operation. Cholecys- 
tectomy gives a high mortality when performed 
on a fat subject with a highly placed suppurating 
or gangrenous gallbladder, especially if performed 
after forty-eight hours. 

Cholangitis usually implies that one or more gall- 
stones have entered the common duct and caused 
stoppage of the flow of bile with resulting infection. 
The most characteristic symptom is jaundice. This 
should always be regarded as a danger signal, as 
the patient has entered a stage of the disease which 
increases greatly the risk to life. Chills, intermittent 
fever, sweats and prostration frequently accompany 
the jaundice, and if allowed to persist may result 
fatally. More frequently the^ obstruction is tem- 
porarily relieved by the stone being passed or 
dropping back, the bile flows again into the intestine, 
and all the symptoms disappear. The choice of the 
time for operation in these cases is a matter of 



judgment on the part of the surgeon. Operation 
is more hazardous at the height of the attack and 
in the presence of jaundice, but if the symptoms 
persist more than forty-eight hours and the patient's 
general condition is growing worse from the absorp- 
tion of septic bile, operation offers the best chances 
and should not be further delayed. Here also the 
simpler and shorter operation for drainage of the 
gallbladder will meet the vital indications and save 
the patient's life in cases where the patient would 
succumb to the more complicated and prolonged 
operation of choledochotomy and removal of the 
stones in the common duct. If the patient is fortu- 
nate enough to recover from the attack of cholan- 
gitis under medical treatment he should not be 
allowed to run the dangers of another such attack 
and operation in the interval is the safest procedure. 
At this time removal of the gallbladder with its 
stones, and removal of the stones in the common 
duct, followed by drainage of the latter by means 
of a tube, are the procedures of choice. It cannot 
be emphasized too strongly that one attack of jaun- 
dice associated with stones indicates operation in 
the absence of other factors that may contraindicate 
operations in general. 

Malignancy starting in the gallbladder is not a 
rare complication of gallstones and is, of course, a 
most serious one. Unfortunately, in most cases the 
carcinoma is too far advanced when diagnosed to 
admit of complete surgical removal. Metastases in 
the liver are not amenable to surgery, and it is only 
when the disease is localized in the wall of the gall- 
bladder that surgery is successful. These are the 
cases that are operated upon under the diagnosis of 
chronic cholecystitis and in which the carcinoma is 
found by accident before it has spread to the sub- 
stance of the liver. Every chronic thickened gall- 
bladder with stones has the possibility of a malig- 
nant change, and hence should not be allowed to 
remain. The appearance of jaundice in these cases 
not associated with signs of obstruction of the com- 
mon duct means involvement of the liver by the 
metastatic growth ,and hence is a most unfavorable 
sign. Operation in these cases is rarely successful. 

The history given by patients with carcinoma of 
the gallbladder is usually, one of repeated gallstone 
attacks extending over a period of several years. 
One is always struck by the pathos of the thought 
that in these cases operation at the beginning would 
have avoided the tragedy of a miserable death from 
cancer of the gallbladder and liver starting from 
the prolonged irritation of the stones which were 
allowed to remain so many years in the gallbladder. 

Operation in delayed cases of cholelithiasis is 
often hazardous. This has already been pointed 
out as true of the acute cases of suppuration, gan- 
grene of the gallbladder, and obstruction of the 
common duct associated with cholangitis. It is also 
true of the chronic cases which are often allowed 
to go on for fifteen or more years. Important 
degenerative changes occur in the myocardium and 
kidneys, which render the patient a poor operative 
risk. Under these conditions operation must not 
be undertaken hurriedly and without adequate 
examination and preparation. If the blood pres- 
sure is too low, the heart action irregular, or func- 



January 1, 1921.] 



LAPENTA: GALLBLADDER LESIONS. 



5 



tional tests of the kidneys insufficient, these must 
be corrected before operation. But even with these 
precautionary measures the operation is often 
dangerous in these long delayed cases and certainly 
much more so than in the early periods of the dis- 
ease before degenerative changes have begun. It 
must be borne in mind that delayed operations are 
as a rule more difficult and prolonged owing to 
more complicated pathology. One encounters firm 
adhesions between the gallbladder and intestines or 
omentum, possibly a communicating opening into 
the intestine, marked thickening and contraction of 
the gallbladder, all of which make the dissection 
difficult and prolonged and add materially to the 
risks incident to delayed operation. The contrast 
between a cholecystectomy on an unthickened non- 
adherent gallbladder and one on a sclerosed adherent 
and deeply embedded one is most striking to t'^ 
surgeon and the onlooker both as regards the diffi- 
culty of the technic as well as the valuable time 
expended on the dissection. The separate exposure 
and ligation of the cystic duct and artery have be- 
come much more difficult and the subsequent danger 
of secondary hemorrhage and leakage of bile from 
sHpping of the ligatures are much increased. The 
removal of the stones from the common duct and 
ampulla of Vater and drainage of the duct add to 
the operative risk and often call for the highest 
degree of technic in order to be successfully per- 
formed. All these dangers can be avoided by opera- 
tion in the early stages of the disease before the 
onset of complicating inflammatory changes and 
migration of stones from the gallbladder into v the 
ducts. The conclusion is unavoidable that early 
operation in cholelithiasis is strongly indicated, and 
that only in this way can the present high mortality 
of this serious disease be lowered. 

14 E.\ST P'iFTY-EIGHTH StrEET. 



PATHOGENESIS AND PHYSIOPATH- 
OLOGY OF GALLBLADDER AND 
BILIARY TRACT LESIONS. 
By Vincent Anthony Lapenta, M. D., 

Indianapolis, Ind. 

The recent advancement in our knowledge of 
focal infections in general has necessitated a revi- 
sion of our conceptions of the pathogenesis of many 
diseases, and incidentally has forced us to view 
many disorders from a physiopathological view- 
point, rather than from that of morbid anatomy 
alone. This change in our viewpoint constitutes a 
great step forward in itself, since this method 
enables us to detect diseases in their incipiency, and 
often, by our knowledge of the pathogenetic pro- 
cess, we are enabled to formulate effective preven- 
tive treatment. 

Diseases of the gallbladder and biliary ducts 
comprise a group of abdominal syndromes of com- 
mon incidence. In fact, gallbladder aPffections are 
second in occurrence only to lesions of the appendix. 
Pathologists report the presence of gallbladder 
lesions associated with' calculi in from five to seven 
per cent, of all autopsy cases. European path- 
ologists have reported even a larger percentage. 



occurrence of gallbladder lesions in 
relation to age and sex. 

The incidence of gallbladder diseases increases 
with age. It is far more common after the age 
of thirty than at any preceding time in life, the 
greatest number of occurrences taking place between 
thirty-five and sixty years. While not very com- 
mon, gallbladder lesions, especially of the acute 
infectious type, are not rare in younger people and 
even in children. Reid (1) has made a collective 
study of acute cholecystitis in children, following 
typhoid fever. We have ourselves observed this 
complication in children. In our first series of 114 
gallbladder cases, we had two cases of acute chole- 
cystitis of probable hematogenous origin ; one in a 
boy of eleven years and the other in a girl of 
seven. Both of these patients had suffered sev- 
eral attacks of tonsillitis. In the boy's case, no 
bacteriological study was made of the bile and 
gallbladder ; in the girl's case, presenting an acute 
suppurative cholecystitis, a cholecystectomy was 
performed, with biliary drainage secured through 
a choledochostomy. Study of the common duct 
bile, on several occasions, gave persistently negative 
findings. The disease seemed to be confined en- 
tirely to the gallbladder. The histopathological 
study of the gallbladder wall showed the presence 
of active inflammation, injection of vessels, round 
cell infiltration, desquamation of the surface epi- 
thelium, small necrotic foci, and, here and there, 
small coagula of plastic lymph. Bqth in the tissues 
and in the pus, it was possible to demonstrate a 
short chain streptococcus. A study of the discharge 
of the tonsillar crypts of the same individual re- 
vealed the same organism. The patient was later 
directed to have her tonsils removed. 

Women are far more susceptible to gallbladder 
diseases than men. Hubbard and Kimpton (2), in 
a series of four hundred cases, found a ratio of 
three to one in frequency. Jacobson (3) reports 
the incidence of four to one in a series of cases 
at the Peter Bent Brigham Hospital. Among the 
predisposing factors, in a way accounting for this 
greater frequency of gallbladder lesions in women, 
may be mentioned their greater tendency to a 
sedentary life, pregnancies with their concomitant 
stress on hepatic function, and high blood choles- 
terol content — a constant concomitant of gestation. 

physiopathology" of gallbladder diseases. 

Before we can hope to get a firm grasp of the 
pathogenesis of these lesions, and even before we 
can attempt to draw any instructive conclusions on 
their surgical and medical treatment, we must 
attempt to get a clear understanding of the physi- 
ology of the biliary apparatus and develop from 
this our physiopathological conception. 

The bile represents a continuous secretion of the 
hepatic cell, little if any influenced by the taking 
of food. But it is not discharged continuously 
into the duodenum. During gastric digestion, the 
amount of bile entering the duodenum is minimal ; 
the amount begins to increase rapidly, as soon as 
protein cleavage products with acid chyme begin 
to enter the duodenum from the pylorus, the height 
being reached when intestinal digestion is at its 
peak. This clearly shows the necessity of a mor- 



6 



LAPENTA: GALLBLADDER LESIONS. 



[New York 
Medical Journal. 



phological and physiological mechanism to store the 
bile during the time that its presence into the duo- 
denum is not needed. Such an anatomicophysio- 
logical mechanism is represented by the gallbladder 
and the sphincter of Oddi, a neuromuscular mech- 
anism, controlling the opening of the common duct 
into the duodenum. 

In 1887 Oddi undertook the study of the func- 
tions of the gallbladder by performing cholecystec- 
tomy in a large number of dogs. This operation 
had already been performed by Zambeccari on the 
advice of Galileo. Oddi's animals all survived the 
operation, without exhibiting any untoward phe- 
nomena. On killing some of these animals, long 
after the operation, he found a dilatation of the 
extrahepatic ducts, the common duct in some in- 
stances being two to four times the original calibre. 
Most characteristic was the dilatation of the cystic 
duct stump, which uniformly assumed a gallbladder 
shape, showing Nature's attempt to reestablish 
integrity of the gallbladder sphincter mechanism. 
These findings led Oddi to assume the presence 
of this mechanism, which in later researches he was 
able ta discover. This epoch making discovery was 
made by Oddi (4) in 1887. This sphincter, com- 
posed of fibres completely dififerent and independent 
from those of the duodenal coat, is easily distin- 
guishable even with the naked eye in the lower 
animals ; it is not so easily distinguishable in man, 
without adequate preparation, on account of the 
thinness of the muscular coats of the duodenum, 
although physiologically, in the human, it seems to 
possess a more highly specialized function. Oddi 
demonstrated that the sphincter can withstand a 
pressure of fifty mm. of mercury or 675 mm. of 
water. By a series of elaborate researches Oddi 
(5) also demonstrated a special nerve mechanism 
and demonstrated the special characteristics of the 
ganglia supplying the sphincter and their inde- 
pendence of the plexuses of Auerbach and Meisner. 
He traced its reflex centre in the spinal segment 
and succeeded in giving a complete explanation of 
this special nerve mechanism. This extraordinary 
great part of his research was later on confirmed 
by the work of many eminent physiologists ; par- 
ticularly prominent of which was the confirmation 
of Oddi's researches by Doyon (6), who succeeded 
not only in completely confirming Oddi's work but 
also in establishing the special cytological charac- 
teristics of the ganglia, controlling the innervation 
of the sphincter. On the interrelated physiology 
of the gallbladder and Oddi's organ, Bruno (7) 
made in 1889 the most classical contribution. By 
excising a circular piece of duodenum surrounding 
the common duct sphincter, thereby preventing any 
injury to its muscle fibres and innervation, and, by 
stitching it to the abdominal wall, he was able to 
observe the discharge of bile during fasting and 
during feeding, and also the influence of the com- 
position of foods on the secretion of bile. 

A noteworthy, recent, confirmatory contribution 
to the original work of Oddi has recently been made 
by Mann (8). He has confirmed the finding of 
the dilatation of the duct after cholecy.stectoniy, and 
its absence, when the sphincter of Oddi is divide^ 
at the same time that cholecystectomy is performed. 



He, too, has emphasized the interrelation of the 
sphincter of Oddi and the gallbladder. Mann fur- 
ther states that the gallbladder adds considerable 
mucus to the bile, and that this mucus is absent 
in bile coming from the hepatic duct. 

PATHOGENESIS OF GALLBLADDER AND BILIARY 
TRACT LESIONS. 

There has been a recent attempt to divide these 
lesions into certain clinical groups and to establish 
certain etiological factors preponderatingly dom- 
inant of each group. While this method has un- 
doubtedly shed considerable light on the subject, 
I fear that, after all, it will lead us back into the 
old ontological nosographism and prevent us from 
viewing pathogenesis from a physiopathological 
viewpoint. It seems to me that it would materially 
simplify our study if we should divide these lesions 
into three general classes, namely: 

1. A — Acute angiocholitis and cholecystitis, with and with- 

out calculi. 

B — Acute cholecystitis, with our without calculi. 

2. A — Chronic angiocholitis and cholecystitis. ' 

B — Chronic cholecystitis, with or without calculi. 

3. A — Cholelithiasis with chronic infection of the gall- 

bladder. 

B — Cholelithiasis, without demonstrable infection of 
the gallbladder or bile. 

The purpose of this physiopathological classifica- 
tion is to emphasize in the mind of the clinician 
the following points : 

A. The existence of a diffuse, acute, infectious 
process, involving the entire biliary tract. These 
acute processes may or may not be associated with 
stone. In most instances, the formation of calculi 
takes place, when the process passes into the chronic 
stage, following attenuation of infection. These 
acute lesions are of course amenable to accurate 
treatment, when the latter is well based on etiological 
factors, which can usually be established. 

B. The existence of primary gallbladder infec- 
tions, both acute and chronic, without involvement 
of the balance of the biliary tract. 

C. The existence of both biliary tract and gall- 
bladder lesions, in the primary acute form, due to 
attenuated infection of hematogenous origin. 

D. The existence of cholelithiasis in the gall- 
bladder and dticts, without acute or chronic infec- 
tion possibly due to a persistent hyperchbles- 
terinemia. 

Little if any importance is now attached to 
the theory of ascending infection from the duo- 
denum, since both from anatomical and physio- 
logical reasons, this seems iinprobable. Of the 
avenues of infection we must consider that of portal 
origin, and that coming from systemic bacteremias 
through the hepatic artery itself and directly to the 
gallbladder through the cjj-stic artery. There does 
not seem to be sufficient evidence to consider an 
avenue of infection through the lymphatic circula- 
tion, since the deflux of the lymph stream .seems 
to be away from, rather than toward, these struc- 
tures. Gilbert and Dominici (9) produced chole- 
cystitis and angiocholitis experimentally, by sub- 
cutaneous inoculation of attenuated typhoid cul- 
tures, in rabbits, and colon bacilli in dogs. Any 
lesion of the intestinal epithelium which can permit 
the passage of bacteria into the portal radicles, must 



January 1, 1921.] 



LAPENTA: GALLBLADDER LESIONS. 



7 



necessarily be considered as potentially productive 
of biliary tract infection ; and the infection of the 
gallbladder can then take place through the infected 
bile. In this instance, we must consider a primary 
insult to the hepatic cell itself ; the gallbladder 
mucosa and particularly the crypts of Luscka becom- 
ing subsequently infected. The gallbladder can, 
however, be directly infected by bacteria brought to 
its structural elements by the cystic artery, from 
any focal infection or bacteremia. Rosenow (10) 
in my opinion has demonstrated this clearly and 
irrefutably. He has further well illustrated the 
tissue tropism of some of the bacteria concerned in 
these infections. The hematogenous avenue of 
infection is undoubtedly the most common one in 
primary gallbladder lesions. In infections of the 
bile capillaries it is indubitably the only one, since 
it seems inconceivable to ascribe even one of these 
cases to ascending infection. 

PATHOGENESIS OF CHOLELITHIASIS. 

The infectious origin of choleli'-hiasis was first 
advanced in 1886 by Galippe (11). Naunyn (12) 
later advanced this theory at the Medical Congress 
at Weisbaden in 1891. Confirmation of this theory 
was later brought by the researches of Welch (13), 
Mignot (14), Cushing (15), and Gilbert and 
Fournier (16). Somewhat startling was the state- 
ment of Naunyn that cholesterin was not a specific 
secretion from the liver, but that it was produced 
from the bile by infection. 

Much discussion is still raging between the 
adherents of the infectious theory of gallstones and 
the supporters of the chemical metabolic theory. 
The partisans of the latter theory seek to explain 
the formation of calculi on the basis of a hyper- 
cholesterinemia. They completely reject the influ- 
ence of infection in stone formation and insist that 
an infectious process can cause gallstones only in 
the presence of a high cholesterin content of bile. 
Henes (17) asserts that many cases of cholelithiasis 
show no demonstrable infection, and reports about 
forty cases of cholelithiasis associated with a high 
blood cholesterol content and free from any infec- 
tious trace. The researches of Aoyama (18) are 
in this respect highly suggestive. By subcutaneous 
injection and by oral feeding of cholesterin and 
some of its esters, he has succeeded in producing 
gallstones or concretions similar to them in many 
instances. 

Cholesterin or cholesterol (Cj^H^gOH) is a com- 
plex monatomic alcohol. It forms esters easily with 
fatty acids. It is insoluble in water. It is present 
in all animal tissues, especially in the central nerv- 
ous system. In bile it is held in solution by the 
bile acid salts and its soaps. The dry corpus cal- 
losum contains as much as fourteen per cent., and 
dried human liver, six to seven per cent. Most 
gallstones contain as high as ninety-six per cent. 
Its physiological role is as yet very mysterious. It 
has been assumed that it acts as a protective agent 
to the red cells, and has been used in the treatment 
of pernicious anemia, with supposedly good results. 
While a large number of cases of lithiasis are asso- 
ciated with a high blood content of cholesterol, I 
feel that it is impossible to establish the pathogenesis 
of gallstones from this basis. The overwhelming 



number of these cases is associated with demon- 
strable infection. Careful study of stones in nearly 
eighty-five per cent, of cases demonstrated a bac- 
terial nucleus, with evidence of infection in the 
gallbladder. That a high cholesterol content of the 
bile is a factor cannot be denied, but it is at best 
only a predisposing one and therefore of little etio- 
logical value. It will be best for us to continue 
to consider biliary concretions as monuments to 
one time living bacteria. 

THE GALLBLADDER AND BILIARY TRACT AS SOURCES 
OF CHRONIC FOCAL INFECTIONS. 

It is very easy in our consideration of the etio- 
logical causes of gallbladder lesions to underestimate 
the importance of chronic infectious processes in 
these structures as focal infection factors, capable 
of multivarious clinical manifestations. Thus we 
have seen numerous cases of chronic pancreatitis 
to be wholly dependent upon subinfection, main- 
tained by disease of the gallbladder. Cures have 
been systematically obtained in this case by chole- 
cystectomy with common duct drainage. Of the 
more distant efYects of chronic gallbladder infec- 
tion, we wish to mention a type of severe secondary 
anemia, associated with an increased fragility of 
the red cells. These cases especially have been 
encountered in association with common duct 
stone, although we have had four cases that were 
associated with chronic cholecystitis only. These 
anemias which had resisted all dietetic and medicinal 
treatment quickly yielded to cholecystectomy. I 
cannot ascribe these results to anything but the 
ablation of this active focus of infection, which 
continuously added to the blood toxic products, 
which acted hemolytically on the red cells. These 
cases must not be confused with hemolytic icterus ; 
they represent a type of secondary anemia due to 
increased fragility of the erythrocytes, which is 
encountered often in all chronic infections. 

The primary object of this contribution is spe- 
cifically restricted to the pathogenesis and physio- 
pathology of these lesions. It is, however, neces- 
sary to mention the occurrence of carcinoma of 
the gallbladder, which often seems to be a terminal 
event of chronic infection of the gallbladder, due 
to the long continued irritation, from the presence 
of stones. For obvious reasons it has been thought 
best to refrain from treating of neoplasms of the 
pancreas causing biliary obstruction. 

Adhering to the limitations set to this contribu- 
tion, no reference will be made to the clinical 
manifestations as bearing on . their diagnosis and 
treatment, with the exception of some brief mention 
of our opinions in this regard. We hope to illus- 
trate the lessons to be drawn from this contribution 
in a future publication. 

CONCLUSIONS. 

1. Diseases of the gallbladder and biliary ducts 
are principally produced through hematogenous in- 
fections. Importance must be accorded in the his- 
tory to the occurrence of typhoid, tonsillitis, and 
other focal infections in the past history of the 
patient. Previous disease of the vermiform appen- 
dix must also be taken into account, as well as 
concomitant incidence of chronic appendicitis. 



8 



KOUINDJY 



MASSAGE IN SALIVARY FISTULA. 



[New York 
Medical Journal. 



2. Oddi's researches show tliat the gall1)la(lder 
is not a functionless organ, and that the addition of 
nuicus in tlie I)ile by the gallbladder is of some 
importance. In uncomplicated cases of cholelithi- 
asis with the al)sence oi structural lesions of the 
gallbladder, without active or ([uiescent infection, 
cholecvstostomy is still sufficient. 

3. Caution must, of course, be exercised to avoid 
leaving in a diseased organ. On the slightest evi- 
dence of chronic infection, cholecystectomy must 
be performed. 

4. The role of hypercholesterinemia in the eti- 
ology of gallstones is regarded as a predisposing 
factor. We feel that the chief pathogenic role is 
to be ascribed to infection. 

5. The role of gallbladder infections as chronic 
foci, capable of setting up systemic metastatic lesions 
elsewhere in the body, leads us to emphasize the 
necessity of timely diagnosis and the importance of 
cholecystectomy as a curative operation. 

REFERENCES. 

1. Reid, M. R, and Moxtgomerv, J. C. : .\cute Chole- 
cystitis in Children as a Complication of Typhoid Fever. 
Bulletin Johns Hopkins Hospital. 1920, xxxi, 7. 

2. Hubbard, J. C, and Kimptox. A. R. : Gallstones. A 
Statistical Study of Cases Occurring at Boston City Hos- 
pital, Annals of Surgery, 61 :53S, 1915. 

3. Jacobson, Coxrad : Gallbladder Disease, A Statistical 
Study, Annals of Surgery, vol. i, September, 1920. 

4. Oddi, R. : Di una specialc disposizione di sfintcre alio 
sbocco del coledoco. Perugia, 1887, quoted by Luciani. L. : 
Human Physiology, 2:214, 1913. 

5. Oddi, R., and Rosciaxo, R. D. : Sulla existenza di spe- 
ciale gangli nervosi in prossimita' delle sfintere del coledoco. 
Monitore italiano di Zooloqia. Firenze, 1894, v, 216-219. 

6. DovoN.: Archives de Phys. norm, et path., 1883,1884. 

7. Brune: Arch, dcs Sciences biologiques de St. Peters- 
burg, 1889. 

8. Manx, F. C. : The Functions of the Gallbladder, An 
Experimental Study, New Orleans Medical and Surgical 
Journal, 1918, Ixxxi. 80-92. 

9. Gilbert and Domixici : Angiocholite et cholecystite 
typhiques experimentales, Coniptes rend Soc. de bid., 5-1033, 
December 23, 18. 

10. Rosexow, E. C. : Bacteriology of Cholecystitis and 
Its Production by Injection of Streptococci, Journal .1. M. 
A.. 63:1835, November 31, 1914. .\lso : The Etiology of 
Cholecystitis and Gallstones and Their Production by In- 
travenous Injection of Bacteria, Journal of Infectious Dis- 
eases, 19:527, 1916. 

11. Galippe, v.: Alode du formation du tartre et de 
calcul salivaire, considerations sur la production des calculs 
en general, presence des microbes on de leur germes dans 
ces concretions, Jour, des Connaisanccs Med., 25 Mars., 
1886, Comp. rend. Soc. des biol., Series 8, 3:116, 1886. 

12. Nauxvn, Bernard: Die Gallensteinkrankheiten, 
Verhandl. d. Cong. f. inn. Med., 1891 ; Cf Nauxvx, Ber- 
nard : A Treatise on Cholelithiasis, Xcn' Sxdenhani Soc, 
158, 1896. 

13. Welch, W. H. : .Additional Note Concerning the 
Intravenous Innoculatton ot Bacillus Typhi Abdominalis, 
Johns Hopkins Hospital Bulletin, 2:121, 1891. 

14. Migxet (Quoted by Hartman, M. H.) : Patho- 
genese de la lithiase, I'resse med., 3 (2 mars.), 1898. Also: 
L'origine Microbiene des calculs biliaires. Arch. qen. de 
W., 2:129, 1898. 

15. Gushing, Harvey: Typhoidal Cholecystitis and 
Cholelithiasis, Bulletin Johns Hopkins Hospital, 9, 91, 1898. 

16. Gilbert and Fourniers : Lithiase biliaire experimen- 
tale, Comptes rend Soc. de biol.. 936 (October 30), 1897. 

17. Hexes, Edwin, Jr.: The Value of the Determina- 
tion of the Cholesterin Content of the Blood in the Diag- 
nosis of Cholelithiasis, Journal A. M. A., 63:146, July 11, 
1914; Surgery, Gynecology, and Obstetrics, 23:91, 1916. 

18. Aovama : Experimenteller Beitrag Zur Frage der 
Cholelithiasis, Deutsch. Ztschr. f. Chir., 132:234, 1914. 

Newton Claypool Building. 



TREATMENT OF S.\LIVARY FISTULiE 
BY MASSAGE AND HOT AIR. 

By PlERRli KOUINDJY, M. D., 
Paris, France. 

The utility of mas.sage in the treatment of wounds 
and ulcers had been proved long before the war. 
Some of my colleagues, Munter, Blach, Lanel, and 
others, have published their observations on the 
treatment by massage and hot air of varicose ulcers 
and other forms of ulcers, which had resisted all 
other therapeutic measures. In 1905 I reported a 
case of an obstinate ulcer of the lower extremity 
cured by massage. The ulcer was situated on the 
anterointerior surface of the left leg. The patient 
had syphilis. He had received internal medication 
and external applications, with no result. Electro- 
therapy, hydrotherapy, and hygienic measures had 
no effect on the ulcer. ^Massage of the tissue sur- 
rounding the periphery of the ulcer caused a healing 
of the entire surface in six weeks by virtue of 
increasing the resistance of the tissues. 

Experience in the war showed that extensive 
wounds with fistulje, or badly cicatrized, atonic 
wounds or suppurating ones, finally cicatrized in a 
definite fashion due to the massotherapeutic efforts 
combined with hot air. My confrere and friend, 
Dr. Cyriax, of London, has recently devised a 
method of treating war wounds by massage. In a 
communication published by his pupil, Dr. Louise 
Bennet, one finds a record of suppurating wounds 
cured by massage. In one case quoted, where the 
patient had a large irregular wound of the left 
thigh twelve cm. in diameter, and another small, 
suppurating wound of the right thigh, with a tem- 
perature of 37.9° C. in the morning and 39° C. in 
the evening, digital massage and profound pressure 
of the periphen,- with movements of both adjoining 
articulations healed the wounds in a short time. 

In my service at the Yal-de-Grace I found that 
massotherapeutic maneuvres combined with hot air 
gave excellent results in the treatment of vicious 
cicatrices of the face in war injuries. The results 
obtained by the use of these two physical agents, 
as the case would indicate, were really remarkable, 
even in cases of keloids which would become more 
supple, less adherent, or even completely detached 
in some cases. Frequently they would lose their 
contractility ; the muscles and aponeurosis would 
become detached. This wottld aid in reestablishing 
facial symmetry in a greater or less degree. This 
combination of massage and hot air in the treat- 
ment of cicatrices of the face and cicatrices in 
general prove that, due to the action upon the tis- 
sues of the cicatrices and the adjacent tissue, they 
produced a favorable modification in the circulation 
and, as a result, in the nutrition of the tissues. I 
then thought that this method, established by ex- 
perience, would exert a favorable action upon the 
lesions of the buccal mucosa in the case of wounds. 
The following case will serve to illustrate this : 

Last year our esteemed confrere, the well known 
stomatologist. Dr. Roy, director of the dental school 
of Paris, referred a young patient to me who was 
suffering from lymphangitis of the right side of the 
jaw, which followed the injection of a quantity of 



January 1, 1921.] 



KOUINDjy 



MASSAGE IN SAIJVARV FISTULAS. 



9 



hydrogen peroxide into the subcutaneous tissue of 
this region. The jaw was transformed into a liuge 
tumor with an extensive lymphangitis. In the 
centre of this inflammatory mass was a scaritied 
area about tlie size of a ten cent piece ; in other 
words, a generalized lymphangitis of the right side 
of the jaw with considerable infiltration and a scar 
forming in the centre. The patient was a girl of 
eighteen. It was decided to use methodical mas- 
sage and perhaps hot air in the treatment. Super- 
ficial and deep rubbings were used as well as manual 
concentric vibrations and digital centripetal pressure, 
combined with a current of hot air, followed by 
an internal application of hot air only. In order 
to facilitate the resorption of the infiltration it was 
decided to use the current of hot air by the buccal 
route and directed on the internal surface of the 
jaw. We used a simple paper tube to direct the 
hot air current. In order to avoid any painful 
sensations from the hot air the mouth was douched 
with warm water from tinie to time between appli- 
cations of the hot air. The lymphangitic pocket 
diminished in size progressively, and at the end of 
a dozen treatments the central area was no longer 
visible, and at the end of fifteen treatments, to the 
joy of the author of the unfortunate accident and 
the patient, the symmetry of the patient's face was 
restored. 

This excellent result encouraged me to attempt 
the method in the treatment of salivary fistulas 
which were refractory to all nonsurgical treatment. 
We soon had an opportunity to try the method 
in a typical case of salivary fistula, and we present 
the following case in which the patient. was cured 
by the method of massage and hot air. 

Case II. — Sergeant C, of 233d infantry, seen 
August 29, 1918, in the fifth division of wounded 
at the Val-de-Grace. There was some impotence 
of the left shoulder caused by an atrophy of the 
periarticular muscles of this articulation, and there 
was a large cicatrix in the cervical region which 
had been caused by the bursting of a shell. The 
patient also presented a fracture of the mandible 
badly consolidated, and a salivary fistula of the 
left side of the jaw. The patient was injured 
June 3, 1918. A curettage was done at the region 
of the fracture of the inferior maxillary bone. This 
procedure was not sufficient, however, as the wound 
continued to suppurate. The surgeon then removed 
a splinter of bone, but the wound continued to 
suppurate. A month later the patient noticed that 
saliva escaped through the opening at the base of 
the wound, especially during mastication. From 
time to time debris would escape through the open- 
ing. When the patient entered the physiothera- 
peutic service he held a compress in his hand as a 
protection from the saliva which escaped from the 
cicatrix. He had been receiving lavage of perman- 
ganate of potash several times during the day, in- 
jected into the external orifice of the fistula. The 
nonconsolidated fracture presented a mobile frag- 
ment surrounded by an inflammatory area especially 
in the region of the fistula. There was also an 
area of congestion of the cicatrix and an infiltration 
of the jaw. 

The general condition of the patient left much to 



be desired. He was badly nourished, had difficulty 
in masticating his food, and in addition there was 
a constriction of the opening of the jaw, the si)ace 
between the jaws being only eighteen millimetres. 

I began to treat the fistula by massage, superficial 
and deep rubbing, and centrij)etal vibrations from 
the periphery to the centre, not touching the fistula. 
At the same time the facial cicatrix was massaged 
to make it more supple, less acDierent, and less con- 
tracted. All of the massotherapeutic maneuvres 
were executed first without hot air, later by a cur- 
rent of hot air over the entire cutaneous surface of 
the jaw and the fistula itself. Finally the current 
of hot air was turned upon the buccal surface 
through the opening of the mouth in such a way 
as to bring it in contact with the internal border 
of the fistula. As the application of hot air occa- 
sioned an increase in the amount of heat aj^plied and 
there was danger of causing a burn, or at least a 
very painful sensation, it was necessary to interrupt 
the application frequently and regularly every two 
or three seconds. The treatments were terminated 
by regular movements of the mouth. 

The treatment began on August 20, 1918, and 
soon gave encouraging results. On September 26, 
1918, an examination revealed the facial cicatrix 
more supple and less adherent, and the edema of 
the jaw had diminished perceptibly. The fistula 
had decreased in size but the saliva still escaped, 
especially at the time of mastication. The patient 
was able to eat more easily and masticate better, and 
he could open his mouth a few extra millimetres. 
On October 19, 1918, the fistula was closed, no more 
liquid escaped, mastication was better, the mouth 
could be opened wider, and the patient was better 
able to eat. The facial cicatrix was more supple, 
but still somewhat fibrous. The infiltration of the 
jaw had disappeared. On December 17, 1918, the 
fistula was completely obliterated, the infiltration of 
the jaw definitely gone, the tissues of the cicatrix 
had a normal appearance, the opening of the mouth 
was about normal, thirty-three mm., and he masti- 
cated his food as though there was no fracture of 
the inferior maxillary bone. In any case the patient 
looked very well. Other treatment he had received 
enabled him to move his shoulder joint and bring 
his arms to the same level. A simple suture brought 
the two borders of the fistula together and removed 
all traces. 

How can we explain the action of massage 
and hot air upon salivary fistulie ? Workers 
who apply hot air therapeutically state that it 
causes a hyperemia, which they also call an active 
hyperemia. This hyperemia causes a local change 
which may be compared to a caustic action. The 
hot air produces in addition an analgesic action 
upon the tissues and a progressive drying of the 
secretions. This last ef¥ect can be compared to a 
resection of the auriculotemporal nerve. As in this 
resection, the hot air causes a decrease in the salivary 
secretion with a resorption of the exudate of the 
infiltrated regions. During massage the action 
is mechanical and reflex. The mechanical action 
exerts a favorable action upon the circulation and 
the reflex action upon the terminal nerves, and an 
increase in the nutrition of the tissues. The result 



10 



Sin-MAA': GASTRIC ULCER AND CANCER. 



[New York 
Medical Journal. 



of the aclioii of the phyNical agents utiHzed, hot air 
and massage, is an improvement in the arterial, 
venous, and lyniphatic circulation. This gives iis 
a clue to the progressive elimination of the morbid 
elements of the wounds and of the salivary fistulae. 

Therefore, we are of the opinion that before 
deciding upon surgical intervention in the treatment 
of salivary fistulae it is essential that we first attempt 
a physiotherapeutic treatment, composed of appro- 
priate massotherapeutic maneuvres, as, for example, 
superficial and deep rubbings, light pressure, digital 
vibrations, and a current of hot air applied by way 
of the mouth to the two surfaces of the jaw, first 
the cutaneous surface, later the mucous surface. 
It is necessary to combine the two physical agents 
so that the hyperemic action of the one is comple- 
mented immediately by the mechanical action of the 
other • so that tlie vital activities of the patient's 
tissues are stimulated and the cicatrization of the 
fistula is completed. 

32 RUE d' Liege. 



GASTRIC ULCER AND CANCER.* 

A Case Report of Each. 
By John W. Shuman, M.D., F.A.C.P., 

Sioux City, la., 

Visiting Physician, St. Vincent Hospital. 

The diagnosis of stomach lesions is greatly aided 
by X ray visualization. The two cases reported 
below illustrate the diagnostic value of radiology 
and the shadows show clearly the pathology present. 




Fig. 1. — (Case I.) Arrow points to deformity on lesser curvature, 
midway between cardiac and pyloric ends of stomach. Position, 
prone. Time, two and one half hours after meal was ingested. 



•Presented at the Twenty-fifth annual meeting of the Sioux Val- 
ley Medical Association, held at Sioux Falls, South Dakota. June 
23 and 24, 1920. 




Fig. 2. — (Case I.) Arrow points to the defurmity which is still 
present at four and one half hours. 



Both patients were operated upon and the surgical 
pathological findings confirmed the clinical diag- 
nosis in each instance. The first case was diagnosed 
clinically as a penetrating ulcer on the lesser curva- 
ture, midway between the cardiac and pyloric ends 
of the stomach. The second case was diagnosed as 
malignant neoplasm involving the pyloric end of 
the stomach and causing pyloric obstruction. 

PENETRATING ULCER ON THE LESSER CURVATURE, 
MIDWAY BETWEEN THE CARDIAC AND 
PYLORIC ENDS OF THE STOMACH. 

Case I. — Mr. P. H., aged seventy, was referred 
by Dr. W. G. Rowley, of Sioux City, on September 
27, 1919.' He complained of a burning sensation 
in the stomach, and gave the history of having had 
a stomach ulcer diagnosed and cured six years ago 
by medical treatment. The highly suggestive symp- 
toms of ulcer, i. e., hunger pain, food ease, and 
hypersecretion, were present. Radiograms of the 
stomach containing the barium and buttermilk meal 
at two and a half and four and a half hours in 
the prone position, showed a constant deformity on 
the lesser curvature (Fig. 1), which was interpreted 
as a penetrating ulcer. At eighteen and a half 
hours the head of the meal was inidway through the 
transver.se colon and a "fleck" (crater of the ulcer) 
was easily observed in about the position where the 
gastric deformity had been noticed the day previous. 

The conclusion was drawn in this case that we 
were dealing with a penetrating ulcer of the lesser 
curvature of the stomach ; but malignancy had to 
be considered on account of the age and appearance 
(malnutrition) of the patient and the history of 
chronicity. Celiotomy was advised and performed 
on October 22nd, and a perforating ulcer, "dime 



January 1, 1921.] 



sHi■^rA^': gastric ulcer and cancer. 



11 




Fig. 3. — (Case I.) Arrows point to shadows which were inter- 
preted as "barium flecks." Note that one is more distinct than the 
others (ulcer crater filled with barium). Position prone. Time, 
eighteen and one half hours. 

size," found situated midway between cardiac and 
pyloric ends of stomach, on the lesser curvature. 
This ulcer was cauterized and excised and a pos- 
terior gastrostomy performed. On January 15. 
1920, Dr. Rowley reported that the man had gained 



Fig. S. — (Case II.) Exposure made fifteen minutes after Fig. 4. 

forty pounds in weight and was feeling "the l)est 
in years." 

MALIGNANT NEOPLASM INVOLVING THE PYLORIC 
END OF THE STOMACH AND CAUSING 
PYLORIC OBSTRUCTION. 

Case II. — Mrs. M. E. G., aged seventy-two, was 
referred by Dr. W. G. Rowley on November 10, 




Fig. 4.— (Case II.) Time, immediate; prone position; arrows FiG. 6.— (Case II.) Exposure one hour after the taking of the 

pointing to filling defect. barium meal shows the deformity copstant and delayed emptying. 



12 KUSE: ACID 

1919. She had lost thirty-fivc pounds in weight 
during the past year, and could not retain food, 
'["here was a freely movahle, smooth, well rounded 
mass ahout the size of a small orange palpable in 
the niidepigastrium. Radiograms made immedi- 
ately, fifteen minutes, one hour, and eighteen liours 




Fic. 7. — (Case II.) At eighteen hours; arrow points to small 
portion of the barium meal stHl -remaining in the stomach. The 
constant deformity and delayed emptying made for the diagnosis 
of a gastric tumor. 

after taking the barium and buttermilk meal, 
showed a marked filling defect in the prepyloric 
portion of the stomach (Fig. 2), which was reported 
by the surgeon after the operation as a turkey egg 
sized mass, of cauliflower appearance, found inside 
the stomach, attached by a pedicle to the wall of 
the stomach, on the lesser curvature about one 
and a half inches from the pylorus. No perigastric 
adhesions and no enlarged glands were found. The 
neoplasm was removed and a gastroenterostomy 
performed. This mass had evidently acted in a 
ball valvelike manner to occlude the pylorus. The 
patient died six days later. The pathological diag- 
nosis of the tumor by Dr. Rowley was adeno- 
carcinoma. X ray exposures and prints were made 
by Maud H. Fair, x ray technician. 

F"rANCES BuiLDINd. 



Occupational Therapy for the Tuberculous. — 

F. H. Hunt (Boston Medical and Surgical Journal, 
Sepember 16, 1920) says that occupational thera- 
py's chief aim is psychic and that, based upon its 
l)sychic ef¥ect, it is a])plicable in all stages of tuber- 
culosis, early and late, favorable and unfavorable, 
each case presenting its own problem, and when 
controlled exercise is added, physical upbuilding 
with enhanced imniunitv results. 



GASTRITIS. [New York 

Medical Jouknai.. 

ACID GASTRITIS. 
By Robert Hugh Rose, M. D., 

New York. 
DEFINITION AND DESCRIPTION. 

Acid gastritis is an inflammation of the stomach, 
characterized by an increased secretion of hydro- 
chloric acid and the presence of an abnormal amount 
of mucus. Mild cases so much resemble simple 
hyperchlorhydria that it is difficult to draw a sharp 
line between these conditions. Severe cases so 
much resemble ulcer that the differential diagnosis 
is made with difficulty. This overlapping of symp- 
tomatology is not strange because increased acidity 
is present in all three and the symptoms are, to a 
considerable extent, due to acidity. While, there- 
fore, it is often largely a difference of degree which 
exists between them, it is important to recognize 
with which condition one is dealing, in order to 
prescribe the proper treatment. In severe cases the 
amount of mucus is so marked that considerable 
attention must be directed to its removal. 

ETIOLOGY. 

Acid gastritis is due to the same causes as hyper- 
chlorhydria. It is questionable whether the latter 
disease can exist for many weeks without producing 
some inflammation of the stomach and, therefore, 
turning into acid gastritis. Since my article on 
hyperchlorhydria (1) gives the causes in detail, I 
will here mention them only briefly. Acid gastritis 
is caused by seasonings, spices, acids, coffee, alcohol, 
tobacco, irregular or rapid eating, overwork, worry, 
violent emotions, and such surgical conditions as 
chronic appendicitis, gallstones, and other similar 
conditions. Infection of more or less severe grade 
is, according to my opinion, secondary to these 
causes. Germs from the nose and throat, as well as 
those taken in the food, afe the source of infection. 

PATHOLOGY. 

The mucous membrane is congested and there is 
])roliferation of secretory glands. When such in- 
flammation is severe, connective tissue may, sooner 
qr later, obliterate some of these glands until the 
disease is transformed into gastritis with subacidity. 

SYMPTOMS. 

Appetite. — On account of the acidity, which pro- 
duces better digestion and often increased motility, 
the appetite is increased. It is well to bear this 
point in mind, and, in cases where the appetite is 
diminished, to look for some complication as 
explaining the discrepancy. The complication may 
be spasm of the pylorus (producing impaired gas- 
tric motility), atonia gastrica, or a large quantity 
of mucus. 

Taste. — There may be a sour taste and this is 
what should be found in uncomplicated cases. 
Inflammation of the bile ducts and of the large and 
small intestines account for the modification of this 
symptom. 

Heartburn. — A burning sensation in the esoph- 
agus or stomach is nearly always present, either 
regularly within one or two hours after meals, or 
on occasions when foods which disagree are eaten. 

Pain. — The pain which occurs with acid gastritis 
varies from a slight to a severe one. It is some- 



January 1, 1921.] 



ROSE: ACID GASTRITIS. 



13 



times described as a burning i)ain because accom- 
panied by heartburn. At times it is sharp enough 
to assume a knifelike character. Owing to the 
tendency for circular muscles at the pylorus and 
cardia to go into spasmodic contractions, there may 
be attacks of pain of a character comparable to 
gallstone, kidney stone, or angina pectoris. Lesser 
degrees of spasm of these muscles produce a sen- 
sation of gnawing rather than actual pain. Spasm 
in the upper esophagus causes a sensation of dis- 
comfort which is variously described as a feeling 
of suffocation, lump in the throat, or choking. 

A'dusea. — It is natural for patients stififering from 
this condition to complain of natisea. When spasm 
of the pylorus causes the acid contents of the 
stomach to be retained, it may produce nausea with 
occasional vomiiling. In the more severe cases, 
which are accompanied by a great deal of mucus, 
vomiting at intervals is Nature's method of remov- 
ing the mucus when it has accumulated. Thick, 
tenacious mucus is more common with a siibacid 
gastritis, but it is present in hyperacid gastritis 
frequently enough to make vomiting of this char- 
acter an important symptom. It must be remem- 
bered that many of these cases are accompanied 
by mucus in the esophagus, and its presence accounts 
for some of the substernal discomfort in the itpper 
part of the esophagus. 

Examination. — Tenderness in the epigastric 
region is more marked than it is in hyperchlor- 
hydria, and it is present during the interval between 
digestion as well as during the periods of digestion. 

Test breakfast. — Examination of the gastric con- 
tents after the usual test breakfast of bread and 
water shows not only increased acidity but the 
presence of muctis as well. 

DIAGNOSIS. 

There is no difficulty in making a diagnosis of 
acid gastritis from the examination of the stomach 
contents. The length of time the disease has 
existed as elicited in the history together with the 
severity of the symptoms will indicate whether 
hyperchlorhydria or acid gastritis is to be expected. 
Mucus in the gastric contents establishes the pres- 
ence of inflammation. The amotmt may not be 
appreciated at first, because thick mucus does not 
always come through the tube when the test meal 
is expressed. It may require several washings of 
the stomach to remove all the mucus present. 

PROGNOSIS. 

Although acid gastritis requires more vigorous 
treatment than hyperchlorhydria, the ultimate prog- 
nosis is not as bad as at first might be supposed. 
The causes, being about the same, are as easily 
removed. Mild cases respond to treatment almost 
as quickly as hyperchlorhydria. The more severe 
cases require great care and persistence in the use 
of therapeutic measures. 

TREATMENT. 

Prophylaxis. — This is the same as in hyperchlor- 
hydria. 

Active treatment. — The diet is arranged in a 
similar way to that for hyperchlorhydria. It is 
necessary to avoid acids, not only vinegar and lemon 
but all fruits which are in the least degree sour, 



such as cranberries, goosei)erries, .sour grapes, 
cherries, apples, oranges, grapefruit, or berries ; 
pies or dishes of any kind which have a sour flavor. 
Sour wines cannot be taken. Articles which are 
oversweetened are also injurious. Mustard, jjcpper. 
hot sauces, spices, and foods which are pungent, 
stich as mint, cress, radishes, turnips, onions and 
garlic are absolutely contraiiulicated. Excessive 
amounts of coffee and strong cigars should bd 
avoided. Meals should be simply pre])ared, avoid- 
ing rich dishes and fried foods and using only 
enough salt to counteract the flat taste. The dietary 
may be chosen from the following articles : 

F«/.y.— Butter, cream, olive oil, and crisp bacon. 

Carbohydrates. — Small amount of sugar, toast, 
whole wheat and graham bread, corn bread and 
muffins (made with especial care so as to be light), 
plain soda crackers, unsweetened whole wheat or 
graham crackers, baked or well mashed potatoes, 
baked sweet potatoes, cereals well cooked or dry 
cereals heated, simply prepared tapioca, lettuce, 
celery, romaine, spinach, string beans, lima beans, 
tender peas, butter beets. 

Proteins. — Roast beef or lamb, broiled steak, 
.broiled lamb or mutton chops, tender veal, fresh 
fish, chicken, and turkey. Milk, cream cheese, 
American, brie, camembert, cheddar, Swiss, Mc- 
Claren's yellow and unsnappy cheese. Eggs either 
poached, coddled, scrambled, soft boiled, or boiled 
for thirty minutes. No pepper, mint sauce, hot 
seasoning, onion, garlic, and only a moderate amount 
of salt shottld be used in the preparation of the 
proteins. 

Drinks. — In addition to milk, which is generally 
well taken, a moderate amount of weak tea, cocoa 
(not too sweet), plain water or alkaline waters 
are harmless. In severe cases a diet as for mild 
ulcer is necessary. 

Drugs. — By the use of a sufficient quantity of 
alkalies the excessive acidity may at once be neutral- 
ized and many of the symptoms, such as sour taste, 
heartburn, pain and headache, cjuickly relieved, and 
the gastric mucous membrane at the same time 
soothed and its inflammation lessened. For this 
ptirpose equal parts of calcined magnesia and 
sodium bicarbonate may be given in doses of a 
quarter to a half teaspoon a half hour to an hour 
after meals, and repeated if necessary two hotirs 
later — making in all six times a day. If this dose 
proves too laxative, a mixture of equal parts of 
bismuth and soda may be substituted in like amount 
for each alternate dose of the magnesia and soda. 
If more laxative is required the amount of the first 
prescription may be increased, or if the acidity is 
not very high, powdered rhubarb may be included 
with a little oil of peppermint to improve the taste. 

Mucus. — The- presence of muctis is a factor in 
this inflammatory process which requires especial 
attention both because it must be eliminated in the 
ctire of the inflammatory process and because it is 
responsible for much of the discomfort which these 
patients" suffer. Twenty minims of sodium glycero- 
phosphate to the teaspoon of water when adminis- 
tered in a glass of hot water a half hour to an hour 
before meals dissolves the mucus and washes the 
stomach. This is an effective measure in that it 



14 



I.ni'V: GASTROENTEROLOGY AND THE MOUTH. 



[New York 
Medical Journal. 



cleanses the stomach three times daily. In cases 
accompanied by hotli a large amount of mucus and 
(il)stinatc consti])ation a substitution of Carlsbad, 
l^l)soni or Rochclle salts in hot water for the 
glycerophosphate before breakfast works admirably. 

Lavage. — Washing the stomach first with soda 
and then with a weak solution of silver nitrate if it 
can be done from three to seven times a week, at a 
time when the stomach is empty, is more effectual 
than the glycerophosphate treatment, and the 
advantage of the use of silver nitrate in this way 
may be seen in the much more rapid improvement 
which takes place when it is employed. The stomach 
is sensitive to silver nitrate and it must be used in 
a weak solution at the beginning with a gradual 
increase in strength, never enough to cause the 
patient pronounced discomfort. A solution of one 
to twenty thousand is strong enough for the first 
lavage. This may be gradually increased, but it is 
seldom necessary to go above one to eight thousand, 
though some patients who have been accustomed to 
very highly seasoned foods may stand one to two 
thousand without discomfort. If it is difficult to 
use lavage and the silver nitrate is strongly indi- 
cated, one eighth to one quarter grain may be 
taken in a glass of water half an hour before each 
meal, but it should not be continued for more than 
three or four weeks. 

REFERENCES. 

1. Rose, Robert Hugh: Hyperchlorhydria, New York 
Medical Journal, April 10, 1920. 

40 E.AST Forty-first Street. 



THE MOUTH FROM A GASTROENTERO- 
LOGICAL VIEWPOINT. 

By Louis Henry Levy, M. S., M. D., 
New Haven, Conn. 

The gastroenterologist is frequently consulted for 
some mouth condition or mouth symptom and as a 
result many unusual things are encountered. The 
mouth is of interest to the gastroenterologist from 
three points of view. Affections of the n;outh may 
produce lesions in the stomach, intestines or even of 
the appendix. Changes in the stomach and intes- 
tines may manifest themselves by symptoms in the 
mouth. Again abnormal conditions within the 
mouth may produce other abnormal conditions of 
the mouth. Ordinarily these latter conditions are 
within the province of that highly specialized divi- 
sion of gastroenterology — stomatology — but since 
this specialty has not as yet been sufficiently devel- 
oped it still falls to the gastroenterologist to 
diagnose and treat mouth lesions with symptoms 
referable to the mouth. 

Conditions arising from within the oral cavity 
are etiological factors in the production of lesions 
in other parts of the gastrointestinal tract. The 
relationship between apical abscesses, pyorrhoea 
alveolaris and tonsillar infections in the production 
of some cases of ulcer of the stomach and some 
forms of appendicitis has been well demonstrated 
by Rosenow who several years ago proved that the 
same organisms removed at operation from excised 



appendices or in the craters of ulcers were present 
about the various structures in the mouth. 

Herschcll and Abrahams in their excellent book 
(1) state that it is probably no exaggeration to 
assert that the commonest factor which determines 
whether a given case of atonic constipation will pass 
into the stage in which it is complicated by colitis 
is the condition of the mouth. Quite apart from 
the efticienc)' of the teeth as a masticating machine, 
the presence of centres of pus infection from which 
millions of virulent organisms are swallowed with 
each mouthful of food must be a constant menace 
to the integrity of the function of the gastrointes- 
tinal tract. 

Colyer (2) states that the food imperfectly masti- 
cated and incorporated with infected saliva sooner 
or later starts a catarrhal inflammation. Septic 
gastritis may result. The septic material from the 
stomach will find its way into the bowel and pro- 
duce either constipation or diarrhea, and in some 
cases mucous colitis. The acidity of the stomach is 
not an absolute antiseptic to the organisms swallowed 
and some of the cases of phlegmonous gastritis 
occasionally reported are examples of bacteria 
attacking the gastric mucosa in the presence of a 
normal gastric acidity. The acid may to some extent 
inhibit but not necessarily destroy bacteria. Chronic 
gastritis in many cases is undoubtedly due to the 
constant irritating action of bacteria swallowed in 
the saliva and with the food. The source of the 
bacteria is the teeth. Such a condition may persist 
for years, often resulting in ulcer and only disap- 
pearing with proper treatment of the teeth. Two 
cases from my records will illustrate this. 

Case I. — Miss R. F., aged twenty-eight, stenog- 
rapher, with gastric symptoms of eleven years' 
duration. The symptoms consisted of sour taste, 
bad breath, occasional nausea, epigastric distress 
after meals, lack of appetite, costiveness and nerv- 
ousness. She had been operated upon twelve years 
previously and the appendix removed. The symp- 
toms at that time were similar to those of which 
she now complained, operation having failed to 
relieve them. Examination showed an undernour- 
ished young woman with marked epigastric tender- 
ness and with tenderness along the ascending colon. 
She had very marked pyorrhoea alveolaris, pus being 
readily expressed in goodly amounts from the gum 
margins. Treatment with proper diet and medication 
resulted in slight amelioration of the symptoms. She 
had been advised to consult a dentist, which she at 
first failed to do. This was insisted upon and with 
careful prophylaxis of the teeth and gums and with 
the extraction of some teeth her symptoms disap- 
peared. She has had no recurrence of symptoms 
in a year and even her weight has increased, from 
ninety-eight to 113 pounds. 

Case II. — Mrs. R. K., forty-five years of age, 
houseworker, complained of epigastric distress and 
pain for six years. The pain had recently become 
almost constant and was aggravated by eating sweet 
foods. The pain had occurred at night. There was 
considerable belching, but no sour taste ; no nausea 
or vomiting. The bowels were costive. She had 
had an appendectomy and ovariectomy eighteen 
years before. Examination showed a faint systolic 



January 1, 1921.] 



LEW: GASTROENTEROLOGY AND THE MOUTH. 



15 



murmur at the aorta. There was severe tenderness 
in the epigastric region near the ensiform. The 
tenderness extended for a sHght distance to the 
right. Fluoroscopic examination showed dilatation 
of the left auricle. 

Treatment, consisting of regulated diet and medi- 
cation, ofifered some relief, but not marked. Fur- 
ther questioning elicited the information that she 
had had occasional trouble with her teeth. They 
appeared to be in good condition, and an x ray was 
advised. A large apical abscess was found, the 
afifected tooth extracted, and the diet and medication 
continued. The symptoms gradually disappeared 
and have not recurred in a year. 

As Rosenow has pointed out, ulcer of the 
stomach may also be caused in some cases by bacteria 
from infections about the teeth. These ulcer cases 
are the direct sequence of chronic gastritis, which 
has resulted from foci in the mouth. I have in mind 
one such case that I saw. A woman aged thirty- 
eight with typical ulcer symptoms of fifteen years' 
standing and especially severe epigastric pain 
after eating, consulted me about her condition. 
Medication and diet only gave occasional relief. 
Although her teeth were flawless a concurrent attack 
of neuritis of the arm aroused suspicion of the 
possibility of an apical abscess. The x ray revealed 
the presence of five apical abscesses. These were 
treated and not only did the neuritis disappear but 
the symptoms of gastric distress also. 

Aside from the countless cases of acute and 
chronic gastritis resulting from rapid or incomplete 
chewing or chewing with poor teeth, there is a 
group who might be properly classified as gum 
chewers. These chew with the bare toothless gums 
or with one plate and one toothless gum. Those 
with the one plate I have found to be women whose 
only reason for using the one plate, which was 
an upper plate, was for cosmetic reasons. It 
prevented the appearance of sunken in jaws. These 
patients had even more difficulty in chewing than 
did those who used the toothless edges of both 
maxillae. The improper mastication, especially of 
the coarser or more fibrous foods and incomplete 
dextrinization of carbohydrates by means of the 
saliva, tend to force food into the stomach in a 
condition which does not allow the gastric juice to 
act properly. The result is delay in gastric diges- 
tion, overactivity of the gastric glands, hypermotility 
and delay in the emptying of the stoniach contents. 
Here are present all the factors for the production 
of an inflamed mucosa. The condition being uncor- 
rected, there follows in due course ulceration and 
even later carcinoma. 

Two patients of mine, both women, one sixty-six 
years old and the other fifty-eight, had for years 
been chewing with upper plates and toothless lower 
jaws. For years their symptoms were suggestive 
of a disordered gastric condition. The cause of 
their gastric condition was apparent and they were 
advised to have lower plates made, which they did. 
With better mastication of their food and correction 
in diet for the gastric condition they were soon in a 
better state than they had been for years. 

With the other class of gum chewers — those 
without any teeth — who have for years been chew- 



ing with their naked gums, I have record of a 
woman of sixty-eight years of age who for twenty 
years had been having gastric symptoms. There is 
another case of a man of fifty-five years of age who 
for four years had been having attacks of symptoms 
pointing to gallbladder disease. Another patient 
whose attacks of epigastric pain were excruciating 
had an area of severe tenderness and resistance in 
the epigastrium that covered a space of about two 
inches. An x ray series showed a chronic pyloric 
ulcer with some obstruction. His condition was a 
surgical one, but he refused operation. He said 
that he would never put store teeth in his mouth. 
After three years, although he is seventy-one years 
old, he still suffers from his severe pains and the 
only relief obtainable is through morphine. 

Case HI. — Still another case was that of a man 
aged eighty years with a gastric history indefinite 
for about six years but more definite for the six 
months before I saw him. He had been gum 
chewing for over ten years. His history and a hard 
mass to the right of the epigastrium was suggestive 
of carcinoma and this diagnosis was verified by the 
X ray. He died before any surgical relief could be 
attempted. 

Symptoms within the mouth suggestive of or 
pointing to conditions in other parts of the gastro- 
intestinal tract are well known. We have come to 
associate the bad, foyl taste and furred tongue with 
a diminished gastric acidity or with constipation. 
We know also that the sour taste and the burning 
in the mouth when it does occur is a manifestation 
of the hyperacid stomach. Cannon (3) states that 
during sleep there is a regurgitation of gastric con- 
tents into the esophagus and often into the mouth 
in small quantities. As a result with the hypoacid 
stomach there is the furred, thick tongue and with 
the hyperacid stomach the clean, red and moist 
tongue. I have seen patients who have told me that 
they were awakened during the night or aroused in 
the morning by a rush of very sour fluid from the 
stomach into the mouth. One patient, a woman 
aged thirty-eight, complained that she was often 
awakened during the early morning hours by a 
sudden desire to vomit and she would eject as much 
as a pint and a half of very acid fluid that would 
not only burn her esophagus and mouth but would 
make lier teeth feel puckery. Examination of the 
fluid showed a free acid content of sixty-eight. 

Another mouth symptom, one not generally 
known and yet indicative of a gastric condition, is 
salivation without local cause. This symptom is 
sometimes present in carcinoma of the stomach. 
The exact mechanism of the symptom is unknown. 
In patients with a definite gastric history suggestive 
of carcinoma this symptom is of the utmost impor- 
tance in the diagnosis. I have a record of two cases, 
one a man aged forty-eight with gastric symptoms 
of only one month's duration. The salivation was 
persistent. X ray plates and operation revealed an 
inoperable carcinoma of the stomach. The other 
patient was a man sixty-five years old and his also 
was a history of short duration, not over two 
months. X ray examination showed a pyloric 
obstruction. He died after exhibiting all the symp' 
toms of a malignant growth. 



16 



/,/:/'}'; GASTROENTEROLOGY AND THE MOUTH. 



[New York 
Medical Journal. 



Tlie third group ot conditions are not as com- 
monly seen by the gastroenterologist as are the 
affections of other parts 6f the gastrointestinal 
tract. The mouth is a common site for the dentist, 
the laryngologist, often the dermatologist, often the 
general practitioner and less often the gastroenter- 
ologist. Frequently a patient with a mouth lesion 
will travel from one to another of all of these 
specialists. Some conditions of the oral cavity 
stand out from the rest and it is these that concern 
the gastroenterologist. 

Perhaps one of the commonest mouth complaints 
is the canker sore. These may be present on the 
tongue, the sides of the mouth, the gmns, the floor 
and the roof. Differentiation as to etiology is of 
vast importance in the treatment. I have seen some 
that were frank cases of Vincent's angina and the 
- organism could be isolated from the sore. Perhaps 
the most characteristic feature about these was the 
odor and the tendency to spread. Another group 
of cases were those with a herpes of the mouth. 
These patients gave a history of nervousness, of 
canker sores occurring at intervals for years and 
of the intense pain of the sores which seeined to 
defy treatment. 

The commonest cases of canker sores are those 
resulting from the action of ulcerated infected teeth 
on the mucosa or from an acid condition of the 
mouth which may be associated with a hyperacid 
condition of the stomach. As a result of this acid 
condition of the mouth, there is produced by the 
action of bacteria on retained food particles between 
the teeth and in cavities, products of decomposition 
which are irritative. After the formation of the 
sores, the acid of the mouth also irritates. 

Salivation without any other symptom is an occa- 
sional symptom and careful examination will reveal 
the presence of either rough or jagged teeth situ- 
ated in the vicinity of the openings in the mouth of 
the ducts from the salivary glands. This condition 
is readily corrected by the proper treatment of the 
teeth. Occasionally the salivation will persist for 
a time after the teeth have l)een treated. When 
such is the case suitable doses of either belladonna 
or atropine will check the salivation. 

One case of salivation was of considerable inter- 
est. The patient, a woman fifty-four years old, 
had been suffering fyr one year from excessive 
salivation following the eating of spicy or vinegary 
foods. Alcoholic drinks would also excite the flow 
of saliva. There was often mouthfuls of .saliva 
excreted. Even the drinking of cider with a low 
alcoholic content' would stimulate this excessive 
flow. Any of these stimulating substances would 
give her a sensation as if her neck and the floor of 
her mouth were swollen. The glands here would 
swell and remain swollen for as long as twelve 
hours. There would also at the same time be a 
swelling of the parotid glands and her cheeks would 
feel full and her face puffed. The condition was 
undoubtedly one of a vasomotor disturbance in a 
patient of a neurotic type. 

Disordered tastes in the mouth are also frequently 
complained of. A commonly encountered patient is 
the one with the bad taste. Here, too, a knowledge 
of the exact cause is of considerable aid in the 



treatment. Aside from the mouth breather with 
the perpetual bad taste in the morning, there must 
be considered the hypoacid stomach with the furred 
tongue. Bad teeth and pyorrhea must be looked 
into and also a less common cause, submucous 
abscesses with a starting point under some cap. 
There must also be thought of the collection of food 
debris in the large crypts of some tonsils. These 
are present in small balllike masses and when they 
are expressed from the crypts the bad taste disap- 
pears. 

Another frequent complaint is the brassy taste. 
Examination of the mouth in these cases will reveal 
the presence in or on the teeth of two different 
metals. They may be a gold cap and a silver, 
copper or zinc filling. When two different metals 
are present in the mouth and there is an acid con- 
dition of the saliva, there is formed spontaneously 
a minute electric cell. An electric current is set up. 
Electrolytic action on the metals occurs with the 
solution of enough of one of the metals to give the 
brassy taste. Neutralization of the acid in the mouth 
usually causes a disappearance of the brassy taste. 

Two cases that were baffling not only to me but 
to others and the diagno.ses of which were only 
made in one case three months prior to death and 
in the other one month prior to death were in the 
fir.st case pemphigus and in the second case perni- 
cious anemia. In the case of pemphigus, the first 
lesions were in the roof of the mouth under an old 
plate and were attributed to irritation from the 
plate. The sores resisted all treatment and gradu- 
ally spread until the lips became involved and later 
the face. When the face was attacked the nature 
of the condition was quite clear. 

In the second case there was a history of a 
burning sensation of the tongue and gums at inter- 
vals for over a year. The attacks usually lasted 
two weeks. The first time I saw the patient he 
had, besides the symptoms first mentioned, burning 
in the epigastrium. There was marked congestion 
of the tongue and lips. Three months after this 
when I saw him again, he complained of a sore in 
his mouth that persisted for a month. On another 
visit three months after the last visit, there were 
other sores in the mouth, and he also complained 
of heartburn and diarrhea. Shortly after this the 
sores began to increase rapidly and there was severe 
pain on swallowing due to other sores on the walls 
of the pharynx. His condition became poorly and 
in the course of examination a blood count was 
made and the hemoglobin determined. The result 
showed the presence of pernicious anemia. The 
patient died shortly afterwards. 

There are many other conditions of the mouth of 
interest to the gastroenterologist. No attempt has 
been made to touch on the luetic, the tuberculous 
or the carcinomatous lesions. The purpose of this 
paper has been simply to tell of some of the inter- 
esting conditions centering about the mouth which 
are frequently encountered by a gastroenterologist. 

REFERENCES. 

1. Herscheli. and Abrah.^ms: Mucous Colitis. 

2. Colyer : Dental Disease in Relation to General Medi- 
cine. 

3. Cannon: The Mechanical Factors of Digestion. 

1172 Chapel Street. 



January 1, 1921.] 



B EH REND: 



UPPER ABDOMINAL CONDITIONS. 



1/ 



SOME UPPER ABDOMINAL TRUTHS AND 
FALLACIES * 

By Moses Behrexd, M. D., 
Philadelphia. 

It was my good fortune to have been a general 
practitioner lor fifteen years and during half of 
this period to have been a socalled internist. Having 
had the opportunity of performing operations in 
my surgical cases it was often possible for me to 
compare the results of medical and surgical treat- 
ment. This preliminary training was undoubtedly 
an important factor in aiding at the arrival of 
conclusions in making diagnoses. It is not only 
important in the preliminary understanding of the 
case but also in postoperative complications, when 
one's training in physical diagnosis assists in the 
treatment of the case. The diagnostic ability of 
the physician is in all probability taxed to a greater 
degree in upper abdominal conditions than in those 
below the umbilicus. 

The main point at issue between the internist and 
the surgeon is the curability of ulcers of the stom- 
ach, as well as the advocacy of the cure of gall- 
bladder conditions by a method to be discussed later 
in detail. From my own early experience I can 
truthfully say that I do not recall a single case in 
which I was reasonably certain that a cure had been 
effected. The internist cannot prove that he has 
cured his patient, even if the radiologist reports the 
ulcer to have healed. The symptoms ot indigestion 
will still remain and it will be finally the surgeon's 
duty to operate. While I would not oppose the 
treatment of ulcers of the stomach or duodenum in 
their inception, still I believe that in a symptomatic 
condition lasting over a prolonged period of time 
surgery is the proper course to pursue. That period 
of time may vary, depending on the individual and 
also upon the symptoms. Medical treatment with- 
out relief should not be extended over a few weeks. 
There must not be a time ^ limit, so to speak, for 
those who have been chronic sufferers from indiges- 
tion for many years. Here the internist does posi- 
tive harm by attempting to cure a socalled healed 
ulcer, perhaps a cancer in its early stages, or a 
fulminating type of cancer in which the symptoms 
reach their height in a few weeks. There is jiist 
as much chance for an internist to cure a callous 
ulcer as there is for an obstetrician to determine 
the sex of the child in utcro. These ulcers usually 
found in the stomach are dense and nonresistant. 
They feel like a scirrhus of the breast. The ulcers 
are often in a mass of adhesions and at times it 
is impossible macroscopically to distinguish them 
from carcinoma of the stomach. The tendency of 
ulcers to undergo a malignant change is another 
argument why these cases should have a timely 
operation. This is a timeworn admonition, but 
there are still many who disregard the warning and 
continue to treat these cases until surgery can do 
no good. 

In duodenal ulcers there is not so great a ten- 
dency to undergo cancerous degeneration, but the 
danger of hemorrhage and perforation of this type 

*Read before the Association of Ex-Resident and Resident Physi- 
cians of the Mt. Sinai Hospital, November 3, 1920. 



is great. \'ery few adhesions surround duodenal 
ulcers, which accounts for the fact that when a 
duodenal ulcer perforates there is a free flow of 
intestinal contents into the abdominal cavity. The 
gastric ulcer may also bleed and perforate. In 
these there may be a perforation without much 
leakage on account of a barrier of adhesions being 
thrown quickly around the opening, preventing 
serious contamination of the abdominal cavity. The 
readiness of gastric and duodenal ulcers to bleed 
and perforate should put these cases in the surgical 
class without subjecting them to prolonged medical 
treatment. 

Speaking of hemorrhage recalls the history of a 
boy, about sixteen 3-ears of age, who was admitted 
to the hospital, suffering from hematemesis. On 
account of a previous history of hemorrhage we 
considered it advisable to operate on him. Prepara- 
tions were accordingly made for the following day, 
but during the night a concealed hemorrhage de- 
veloped and he died before morning. 

What, then, is the proportion of cases which the 
surgeon cures, compared with those cured by the 
internist ? Medical cures are few, while the sur- 
geon who is able to excise these ulcers, preferably 
by means of the cautery, has a large percentage of 
cures. There is no question that excision of the 
ulcer bearing area and a properly placed gastro- 
enterostomy give the best results. A gastroenter- 
ostomy is not essential in every case. It depends 
upon the situation of the ulcer and the judgment 
©f the operator as to whether the incision has en- 
croached too far on the lumen of the stomach. 
There is no question that the patient is cured of 
an ulcer that has been excised, but this does not 
prevent a recurrence of ulcers. These may be at 
a different site in the stomach or at the gastro- 
jejunal opening. A recurrence at the latter posi- 
tion is due to the same process that caused the 
original duodenal ulcer and not to the use of non- 
absorbable suture material. This technical ques- 
tion, however, need not be discussed fully here. 
Suffice it to say that in all the gastroenterostomies 
which I have performed or reopened, the non- 
absorbable suture was not the cause of marginal 
ulcers. 

The fact that patients return to the internist after ' 
operation does not mean that the particular opera- 
tion has failed. Contributing factors are indiscre- 
tion in diet, improper postoperative treatment, and 
inability or refusal of the patient to put himself 
in the hands of the internist so that his future 
course may be guided by him for at least a year. 
This probably is the most important part in the 
final cure of ulcer patients following operation. 

The recent work of Lyon on the biliary secretions 
may be important from a diagnostic viewpoint, but 
it has led to numerous fallacies. It is a diagnostic 
aid determining solely by the character and appear- 
ance of the bile which portion of the biliary tract 
is diseased. This is done by means of a duodenal 
tube. I have tried the test in cases of chronic 
jaundice, but did not meet with any success. The 
reason was evident at the operation, when the fol- 
lowing diseased conditions were found: In one case 
there was a stricture of the right and left hepatic 



18 



BHHREXD: UPPER ABDOMINAL COXDITIOXS. 



[New York 
Medical Journal. 



ducts; in another, there was a new growth in the 
head of the pancreas ; in a third, there was a stone 
tightly impacted in the papilla of Vater, and so on. 
It is apparent, therefore, that even from the view- 
point of diagnosis the test is not necessary, but it 
does complete the study of these cases. 

In regard to chronic jaundice it is unfortunate 
that many physicians consider that the longer the 
jaundice exists the less danger will there be of 
hemorrhage following operation. The trouble in 
the past has been that the waiting period before 
operation has been extended entirely too long. It is 
difficult to give any hard and fast rules to follow, 
but I believe two to four weeks' observation and 
study are sufficient. The urgency of the symptoms, 
such as the presence of Charcot's fever, intense 
itching, and other constitutional symptoms, ought 
to make some impression on the internist. The 
danger in waiting is due to the degeneration of the 
organs, the heart especially, the liver itself, the 
spleen, and the sympathetic system. Prolonged 
complete obstruction will have the same effect on 
the liver as a stone will have on the kidney, namely, 
the liver will practically cease to functionate. It 
has been my experience that if, upon opening the 
common duct, watery bile exudes, a guarded prog- 
nosis must be given. The following case will l)e of 
interest : 

C.^SE I. — A woman, aged sixty-two, with a history 
of a cholecystectomy having been performed a few 
years ago. A second operation was performed by 
me two and a half years ago for chronic pancreatitis. 
At that time her common duct was drained with 
a T tube for eight months. The patient remained 
well following the last operation until two weeks 
ago, when she became intensely jaundiced, followed 
by chills, fever, and sweat. To guard against any 
possibility of bleeding we gave the woman a vene- 
clysis of two per cent, calcium lactate solution tho 
day before operation and immediately following- 
operation. There seemed to be a greater tendency 
of the blood to coagulate following this treatment. 
It must be borne in mind, however, that all measures 
used to prevent hemorrhage in these cases may be 
fruitless. The head of the pancreas in this case was 
of stony hardness, carcinoma being suspected. The 
common duct was greatly dilated and resembled a 
coil of intestine. It contained about four ounces of 
bile. An anastomosis was made between the com- 
mon duct and the stomach. The first twenty-four 
hours the patient vomited large quantities of bile, 
after which the vomiting ceased following gastric 
lavages. On the second day her color had changed 
from deep yellow to pale yellow. The patient made 
a good recovery. 

In contrast to this case let me cite the following, 
which shows the inadvisability of waiting too long. 

Case II. — A woman, about forty-five years of 
age, was operated on for chronic jaundice, the dura- 
tion of which was several months. Her myocar- 
dium was already aflfccted and her kidneys were 
not normal. In this case a .stone was found tightly 
imbedded at the papilla of Vater, necessitating a 
choledochoduodenotomy. The patient did well for 
forty-eight hours, when the myocardium gave way 
niul she succumbed to the deleterious effects of long 



continued jaundice. There was no secondary hem- 
orrhage in this case. 

It would be a mistake, in a paper of this char- 
acter, not to present for your consideration cases 
in which it was difficult to make a diagnosis. A 
case of great interest was that of a young man on 
whom we had operated two years ago for acute 
appendicitis. Four days before admission he com- 
plained of upper abdominal pain coming on sud- 
denly. Examination revealed a rigid abdomen, the 
patient's expression was anxious, but a rather odd 
feature was that vomiting was not an important 
symptom. A diagnosis of ruptured duodenal or 
gastric ulcer was made. At operation there was 
found comparatively little of the contents of the 
duodenum in the peritoneal cavity. The perforated 
ulcer was excised with the cautery. A gastroenter- 
ostomy which had been our custom in the past was 
not made. The abdomen was washed with quarts 
of salt solution. This patient made a good recovery. 

The brother of a Philadelphia physician was 
taken suddenly ill about 7 a. m. He imme- 
diately went to his office, where on examination 
was found a universally rigid abdomen. He 
had vomited and felt nauseated. His skin was 
cold, his face pale, and he seemed to be in a .state 
of shock. There was a previous history of indiges- 
tion. I confirmed all the subjective and objective 
symptoms and made a diagnosis of a ruptured gas- 
tric or duodenal ulcer. At operation no perfora- 
tion was found, but instead a subacute appendicitis. 

A woman about forty-five had been under the 
care of a competent general practitioner for some 
time, who had observed her in several attacks which 
he thought was appendicitis. The pain was always 
in the right iliac fossa until the last attack, when the 
pain occurred higher up and also radiated to the 
left side of the abdomen. The physician then be- 
came suspicious of gallstones, which diagnosis was 
confirmed with the coexistence of chronic appendi- 
citis. At operation the pathology was found as 
diagnosed, but in addition an abscess of the pan- 
creas was revealed. This was opened and drained. 
The pain on the left side can be accounted for by 
the abscess of the pancreas. 

In conclusion, it must be evident to you all that 
the closest cooperation must exist between the in- 
ternist and the surgeon. While the internist should 
treat gastric and duodenal ulcers in their inception, 
considerable harm has been done by the watchful 
waiting poHcy. It is impossible to cure the hard, 
callous ulcer without operation. The internist can- 
not prove he has cured his ulcer patient, while a 
thorough operation will. After operation, patients 
nust be impressed concerning the necessity of plac- 
i;ig themselves in the hands of a co npt'ent phv- 
sician for at least a year. It is a fallacy that the 
longer jaundice is present the less likelihood will 
there be of a secondary hemorrhage following 
operation. 

The sooner operation is performed in ca.ses of 
chronic jaundice, the better will be the prognosis. 
The metliod advocated by Lyon completes the study 
of the case and assists in the diagnosis, but cannot 
be considered useful as a curative measure. 

1427 North Bro.\d Street. 



January 1, 1921.] 



SAPHIR: CAUSES OF PRURITUS ANI. 



19 



CRYPTITIS AXD 1 1 VPERTROPHIED 
PAPILLA AS CAUSES OF 
PRURITUS ANI* 
By J. F. Sapiiir, M. D., 
New York, 

\'isiting Surgt'cm, Diseases of the Rectum ami Anus, People's Hos- 
pital; Assistant Surtfein, Rec'al Department, Out Patient De- 
partment, Gouvcrneur Hospital; Chief of Clinic, Rectal 
Department, Stuyvesant Polyclinic, Etc. 

At the junction of the lower portion of the rectum 
with the anal canal is a distinct Hne of demarcation 
known as the white hne of Hilton, also known as 
tlie mucocutaneous junction. Here are situated the 
anal papilla? and the crypts of Morgagni. These 
papillae, from three to twelve in number, look like 
small tits, or small saw toothlike triangular projec- 
tions. Concealed behind these papillae are the 
openings of the crypts of Morgagni, or anal pockets. 
Some of these are merely slight depressions, and 
others form distinct sinuses. This area, known as 
the anorectal line, linea dentata, or the white line 
of Hilton, is of especial interest because it is the 
seat of inflammatory conditions which present symp- 
toms out of all proportion to the lesion affecting 
them. 

Hypertrophied papillae and cryptitis are the most 
frequently overlooked causes of pruritis ani. You 
will often find patients who have undergone an 
operation for hemorrhoids, which had been diag- 
nosed as the cause of the pruritus, still suf¥ering 
from itching as severe as before the operation. 
These patients as a rule have been and still are 
victims of cryptitis. On using a bent probe, the 
inflamed crypts can be located running into and 
underneath the puflfed up skin tags, and can be 
located in the same manner as when searching for a 
blind internal fistula. 

Those patients who have had external and in- 
ternal hemorrhoids removed at the same time, have 
their crypts removed with the external hemorrhoids 
and are cured of the pruritus. We take for granted 
that the pruritus these patients have been suffering 
from was due to no other cause than cryptitis, which 
was masked by the fact that the patient was a 
sufferer from internal and external hemorrhoids, 
and the severe itching was attributed to them rather 
than to the real cause. 

These crypts act the same as blind internal fis- 
tulae, and most of these fistulae have their original 
focal points of infection in the crypts of Morgagni. 
These crypts often get clogged up, and an inflam- 
matory process follows, resulting in the formation 
of an abscess, which gives the usual symptoms of 
a perianal or a perirectal abscess, and these often 
extend and produce large perianal, perirectal, or 
ischiorectal abscesses. The crypts of Morgagni, 
when inflamed or infected, cause a discharge of 
various types of bacteria, depending upon the type 
or types causing the infection, and the continued 
irritation caused by the discharge produces first 
itching or pruritus, then the condition becomes ag- 
gravated by scratching. Patients suffering from 
cryptitis will invariably complain of itching espe- 
cially intense after defecation, due to the secretion 
or discharge being expressed from the crypts by the 

*Presented at a meeting of the Clinical Society of the Out Patient 
Department, Gouverneur Hospital, November 4, 1920. 



exjiulsion of the fecal mass and spread about the 
. anus. 

The hypertrophied papilhc arc the most frequent 
cause for the socalled neuralgia of the rectum, 
produced by the contraction of the sjjhincter muscle 
upon the hypertrophied papillae, and the pressure 
produced upon the nerve endings of the papillae 
transfers and transmits the pain. 

Frecjuently small masses of fcca! matter or 
foreign bodies are arrested or become lodged in 
these pockets and produce local and reflex irritation. 
The crypts become clogged, and the decomi)osition 
of the fecal matter or retained secretion causes irri- 
tation, followed by inflammation called cryptitis, 
which frequently goes on to pus formation! The 
accumulated discharge overflows from the crypt, 
causing moisture, irritation, excoriation, and itch- 
ing of the anus. 

Frequently patients complain of a prickling pain, 
or of an uncomfortable feeling immediately after 
stool. Others complained of this pain at no other 
time than immediately after stool, probably caused 
by some of the hypertrophied papillae being caught 
in the grasp of the sphincter muscle, and the itching 
produced by the expression of the discharge from 
the crypts during defacation. 

The hypertrophied papillae, when caught in the 
grasp of the sphincter muscle, cause as severe pain 
as that produced by anal fissure, which is caused 
by hard stool getting caught in one of these 
semilunar valves, and this is torn more and more 
at each succeeding fecal movement, until a raw 
ulcerated surface is produced, which is stopped only 
at the mucocutaneous junction. 

Inflammation of the papillae and hypertrophied 
papillae are frequently associated with cryptitis, and 
where a cryptitis exists the hypertrophied papillae 
act as dams, preventing the discharge from the 
crypts, and resulting in abscess formation. Treat- 
ment consists in removing the papillae, when hyper- 
trophied, under local anesthesia, and in opening and 
cauterizing the crypts when inflamed or infected. 
Inject a one fifth or one sixth per cent, solution 
of quinine and urea hydrochloride into the base 
of these hypertrophied papillae and snip the papillae 
off as close to the base as possible. By everting 
the anus, you may bring the papillae into view, or, 
if necessary, use a fenestrated rectal speculum for 
the purpose. It is never necessary to use a general 
anesthetic. Bleeding is a negligible quantity, and 
the after treatment consists of local applications of 
silver nitrate, ten per cent., or ichthyol in glycerin, 
ten per cent., or balsam of Peru every other day 
until the parts are healed, usually two to four weeks. 

For cryptitis inject the parts of area about the 
crypt, including the hypertrophied papillae, and 
excise the crypt and the papilla in a V shaped 
incision, cauterize the base of the crypt with silver 
nitrate, ten per cent., and treat as above. With a 
bent probe one may locate the crypts, and frequently 
topical applications of pure ichthyol by means of the 
probe dipped into the ichthyol and passed to the 
bottom of the crypt, may clear up an ulcerated and 
inflamed crypt. 

Case I. — H. S., fifty-six years old, referred to 
me by Dr. A. J. Zobel, of San Francisco, gave a 



20 



s.ii'iiiK: Causes oi- rkChTrus axi. 



I Xkvv Vok k 
Medical Joursai.. 



history of constipation for the past fifteen years, 
otherwise no trouble until six months ago, when he 
noticed itching in and about the anus and a soreness 
on the left cheek of the buttock near the anu>. 
This itching would at times spread anteriorly to 
the scrotum. He had received treatment at the 




Fic. 1. — A, Houston's valves; R, longitudinal muscular coat; C, 
rectal ampulla; D, columns of Morgagni; E, crypts of Morgagni; 
F, external sphincter; G, Internal sphincter. 

hands of a few physicians and by means of salves 
and suppositories got ;?light temporary relief, but 
the itching .still persisted and unconsciously he 
scratched the parts, so much so tbat the parts grew 
sore from the scratching, lixamination revealed 
the parts reddened, skin cracked, moi.sture and red- 
ness over the anus and anteriorly involving the 
scrotum ; no protrusions, no induration except a 
thickening of the skin, giving it a leathery feel ; 
some scratch marks, and a puffiness of the skin 
which ordinarily would be pronounced skin tags or 
external hemorrhoids. On everting the anus, espe- 
cially over the puffed up skin, and having the patient 
strain down, I could notice small papillae behind 
which were inflamed crypts. These became very 
distinct and, on inserting a bent probe, the tip of 
the probe could be felt moving with freedom under- 
neath the skin on manipulation of the probe. This 
actually can be considered a blind internal fistula. 
Under local anesthesia of quinine and urea hydro- 
chloride, one fourth per cent., I slit the tract open, 
the same as I would in a blind internal fistula, 
trimmed the edges to prevent interference with 
proper drainage, cauterized the base with ten per 
cent, silver nitrate, inserted a small drain ; the man 
went about his business and called for his local 
aftertreatment every other day for the first week. 



and then once a week after that; and after twelve 
treatments was cured. He is well today. 

Case H. — C. J., forty-nine years old, referred 
to me by Dr. J\I. I.ewson, clothing salesman by 
occupation, felt well until eight months ago, when 
he began to notice itching, especially severe at night ; 
he also had itching during the day which was so 
intense that it interfered with his business. In the 
midst of a conversation with a customer, his hand 
would automatically or reflexly go to his buttocks 
or anus, which he was compelled to pat or touch 
because he was ashamed to scratch, and, as he 
described it, "the more you touch or pat the part, 
the more it itches." He got so that he was ashamed 
to wait on a customer. He received treatment at 
the hands of a few physicians by means of salves 
and suppositories, and was treated for eczema by 
one or two doctors, but without relief. He had no 
protrusions, had no swellmg or abscess at any time, 
his bowels moved regularly, had never noticed any 
blood or mucus with his stool, but he complained 
very much of itching after a bowel movement; 
the parts were ver}- wet, and the moisture from the 
anus went down to the scrotum, causing also itch- 
ing of the scrotum. His chief complaint was mois- 
ture and itching, especially severe at night and 
immediately after stool. Examination revealed a 
condition almost the same as above, a cryptitis. 

Under local anesthesia of quinine and urea hydro- 
chloride, one fourth per cent., the crypts were slit 
open, the edges trimmed to insure proper drain- 
age, the base of the cry])ts cauterized with ten per 
cent, silver nitrate, a small drain inserted, a gauze 
dressing and a T binder applied, and the j^atient 
went home to return every other day for treatment. 
He obtained immediate relief from itching, and was 
able to attend to business without the fear of the 
necessity to .scratch preying upon his mind. 

Case HI. — A. R., twenty-eight years old, opera- 
tor, gave a history of having had protrusions and 
much itching for the past two years ; went to a 
doctor who treated him for piles with salves and 
suppositories, without relief. He could not sleep 
at night on account of the itching, and this itching 
became more intense after inserting the supposi- 
tories. Three months' ago he was operated upon 
at the Post-Graduate Hospital, was in the hospital 
for a week, but had had no relief from the itching ; 
in fact, he asserted that the itching had become more 
intense since the operation. He could not sleep 
on accoimt of the itching, which awakened him three 
or four times during the night. He had no blood 
or pus, no pain or protrusions. He had occasionally 
made the parts bleed from the vigorous scratching, 
consciously or unconsciously. Examination re- 
vealed very red, inflamed, and angry looking but- 
tocks and anus, the redness and inflammation reach- 
ing anteriorly to the scrotum and involving the 
dorsum of the penis, and posteriorly over the skin, 
reaching a line parallel with the tip of the coccyx. 
The .skin was .scaly and thickened, covered with 
scratch marks, .some puffiness of the skin about 
the margin of the anus (skin tags), which, on being 
everted, exposed to view a number of hypertrophied 
papilla?, behind which were large openings of in- 
flamed crypts, from which was noted a mucoid 



January I, 1921.] 



DRUECK: EXCISIOX Of CANCEROUS RECTUM. 



21 



secretion. A diagnosis of cryptitis was made, and 
under local anesthesia, as described above, I slit open 
four inflamed crypts, removed the hypertrophied 
papillae, cauterized the bases of the crypts, applied 
the gauze dressing and T binder, sent the patient 
home, and for the first time in thirteen months 
that patient slept through the night. He has been 
relieved of itching and the inflamed condition of 
the parts, and is attending to business. 

Case IV. — S. R., fifty-seven years of age, manu- 
facturer, referred to me by Dr. Arnold Sturnidorf, 
gave a l\istory of having felt well until nine months 
ago, when he noted itching of the anus. He sought 
relief at the hands of a number of doctors, without 
success. He was sent to a prominent skin specialist 
who said he had eczema ; he was treated for that 
condition but without relief. He still had the 
severe itching, more severe during the day and 
when walking, and recently this, itching had begun 
to disturb his nights. He had also noted moisture 
and wetness of the parts ; no blood, no pus, no pain, 
nor mucus. Examination revealed four distinct 
inflamed crypts, which I slit open under a general 
anesthetic, kept him in the hospital three days, and 
since then he has had no itching whatever. 

It may be of interest to note that in all of these 
cases I have been able to segregate successfully the 
Streptococcus fsecalis, and have used the autogenous 
vaccine without much success, although in about 
thirty-six cases of pruritus ani, the autogenous vac- 
cine of Streptococcus f scabs worked like a charm. 
, In fact, in one case in particular, a doctor, of 
Binghamton, N. Y., who had suffered from pru- 
ritus ani for over fifteen years, and who had tried 
almost everything that was invented either to relieve 
or cure itching, got no relief whatever until I had 
prepared for him a bottle of autogenous vaccine 
of a culture of Streptococcus fascalis removed from 
one of his inflamed crypts, and which he injected 
himself. He obtained absolute relief from itching- 
after the second injection, and when I last heard 
from him he was entirely well. 

However, I consider the removal of the cause as 
the safest and most permanent form of treatment 
to effect a cure. The Streptococcus faecalis, an 
aerobic bacillus, is one of the most fre(|uent inhab- 
itants of the crypts of Morgagni, and is the most 
frequent offender in causing cryptitis and its result- 
ing pruritus ani. The injection of an autogenous 
vaccine (not a stock vaccine) has been successfully 
used in making the Streptococcus faecalis inactive, 
relieving the pruritus, and in healing the inflamed 
crypt, but by slitting open the inflamed crypts and 
obHterating the canal as you would in a blind 
internal fistula, you entirely do away with any 
desirable or ideal location for the growth of the 
Streptococcus faecalis. 

345 West Eighty-eighth Street. 

A Contribution to the Histopathology and His- 
togenesis of Syringomyelia. — G. B. Hassin 
(Archives of Neurology and Psychiatry, February, 
1920) concludes that in syringomyelia we possess 
a number of specific pathological changes which 
totally differ from those to be found in any other 
spinal cord lesion — changes which stamp syringo- 
myelia as a distinct anatomicopathological entity. 



EXCISION OF CANCEROUS RECTUM 
THROUGH VAGINAL SECTION. 

By Charles J. Drueck, M. D., 
Chicago, 

Professor of Rectal Diseases, Post-Graduate Medical School anil 
Hospital, Rectal Surgeon to People's Hospital. 

In women ])atients the perineal removal of can- 
cer of the rectum may .sometimes be much facilitated 
by section of the posterior vaginal wall and 
perineum. The operation is practical only when 
tumor is movable, and is situated in the lower half 
of the rectum. If it is as high as the rectosigmoid 
junction, then the combined abdominal and vaginal 
operation should be employed. It is quickly per- 
formed with less technical disadvantage because 
ample working space is provided. There is less 
traumatism and hemorrhage, and consequently les^< 
shock. The technic can perhaps be best described 
in the following case : 

Case I. — Mrs. D., aged forty-eight years, had 
borne eight children of whom six were living; the 
other two died in childhood. Menstruation was 
regular and normal up to eighteen months ago but 
none since then. About one year ago there was a 
])rotrusion at the anus about the size of a lima bean 
(said to have been a hemorrhoid), which disap- 
peared under treatment by her physician, and had 
not reappeared. There was no protrusion at 
present. For the past six months she had lost 
blood from the anus. It came in gushes without 
relation to her bowel movements and was some- 
times so severe as to cause her to faint. Her former 
weight was 200 pounds ; weight today 163 pounds. 
She had had no formed bowel movements for the 
past two months, and lately had had only liquid 



Fig. 1. — A schematic illustration of the location of the cancer. 

stools obtained by the use of Epsom salts. There was 
a feeling of weight and a bruised or sore feeling in 
the rectum, but no definite pain. She said she could 
not have an evacuation without the use of 
cathartics, which produced a temporary flushing 
accompanied with much colic. She had abstained 




22 



DRUECK: EXCISION OF CANCEROUS RECTUM. 



[New York 
Medical Journal. 




Fig. 2. — Vaginal wall incised 
and the rectum exposed. 



from eating rather than use the saHnes and had 
subsisted on toast, soup and tea for the past month. 
Inspection of the anus was negative; it was in its 
proper location, not retracted and pr sented no 
protrusion. 

In a digital examination of the rectum '■•e finger 

entered the rxtuu for 
about an inch and a 
half, when it came in 
contact with an ede- 
matous fold of mucous 
membrane through 
which there was a very 
small passage. The in- 
dex finger could not be 
introduced and the re- 
sistance was firm and 
hard. At the first touch 
the swollen mucous 
membrane felt like an 
intussusception, but the 
deeper feel of the mass 
behind was very dif- 
ferent. The growth 
appeared free from the sacrum but attached to the 
uterus. 

Vaginally, the tumor was easily defined, beginning 
two inches from the vulva and extending up behind 
the cervix. The vaginal mucous membrane was 
free from the tumor, but the uterus was fixed. 
Bimanually, an index finger in the rectum and a 
hand above the pubes determined the mass almost 
filling the pelvis. The x ray photo showed a large 
mass filling the rectum, but no evidence of dis- 
ease in the_ colon above. The patient was told 
frankly that she had a cancer of the rectum which 
was occluding the lumen of the bowel. This latter 
fact she realized all too well and also that she was 
starving on the diet allowed herself (Fig. 1.) 

We suggested: 1. Exploratory laparotomy, at 

which time the bowel 
would be opened and 
an abdominal anus or 
a temporary inguinal 
colostomy provided, de- 
pending upon the con- 
ditions found within 
the abdomen. 2. If at 
this operation it was 
thought feasible to re- 
move the tumor later, 
that such procedure 
would be recommended 
in two weeks, when 
she would be stronger 
than at present. The 
patient accepted opera- 
tion. 

The abdomen was 
opened with a long 
median incision 
through the linea alba, extending from below the 
umbilicus to close to the symphysis. A liberal 
opening was necessary to allow working space. 
The descending colon was palpated and found 
filled with hard fecal masses about the size of 





Fig. 3. — Rectum dissected free 
and the levator ani muscle di- 
vided and held by clamps. 




walnuts. No mesenteric glands were palpable, and 
no evidence of cancer was found in the descending 
colon. The liver was also found smooth, of nor- 
mal size, and without metastasis. From these 
findings it was decided to excise the neoplasm, but 
because of its extent did not seem possible to bring 
down the sigmoid and 
reestablish the anus at 
its normal location. An 
abdominal anus was 
therefore decided upon. 

Two weeks of con- 
valescence were al- 
lowed, during which 
time intensive feeding 
was encouraged. The 
bowel w^as emptied and 
the toxemia relieved. 
T!:e patient quickly 
rebounded from her 
depressed condition and 
was in an entirely more 
hopeful condition when 
excision of the rectum 
was recommended. She 

then received the usual pic. 4.-Tumor dissected tree, 

preparations for a Vag- gasped by intestinal damp and 
4 ^ * excised. • 

nial operation and was 

placed in the exaggerated lithotomy position, the 
hips slightly raised. A final examination was m^ide 
under anesthesia arid the tumor was easily mapped 
out by way of the vagina. It began just above 
the internal sphincters and extended up behind the 
cervix, but was free from both the uterus and 
sacrum and was. movable in the pelvis. The peri- 
neum and vagina were 
cleaned once more. The 
rectum below the neo- 
plasm was swabbed 
with hydrogen perox- 
ide, dried with swabs, 
mopped with alcohol, 
again dried, and then 
filled with a gauze plug 
to otclude its lumen 
and fill it out, thus 
facilitating the subse- 
quent dissection. The 
vagina was held widely 
open with broad , re- 
tractors, the cervix held 
up with a vulsellum and 
a transverse opening in 
the vaginal wall made 
into the Douglas pouch. 
The posterior vaginal 

wall was then incised Fig. 5.— Closure of the peri- 

i-^r^rr^ ^a^,,^-^ +^ wound alter the stump of 

irom ine cervix tO__£ne ,he bowel bad been brought down. 

fourchette, and the in- 
cision carried across the perineum to within a half 
inch of the anus, and a circular incision made around 
the anus. By blunt dissection laterally the vagina and 
perineal body were reflected from the diseased rec- 
uim (Fig. 2). As we reached the lateral borders of 
the rectum the levator ani and transverse perineal 




January 1, 1921.] 



VAX HOOK: COLON INJURY IN NTlPHRECTOM) 



23 



muscles were exposed and grasped with long forceps 
before cutting from the rectum (Fig. 3). These 
muscles contain the superficial and transverse peri- 
neal and the inferior hemorrhoidal arteries which 
will cause sharp hemorrhage unless seized before 
being cut. The number of these vessels is some- 
what inconstant, and instead of there being one 
inferior hemorrhoidal artery, two or three small 
vessels may arise from the internal pudic. There- 
fore, active bleeders are to be looked for at all times 
and picked up as found. The small vessels and 
oozing are controlled by hot compresses held by the 
assistant. There need be very little loss of blood. 

Beyond these muscles the dissection was quickly 
accomplished through the fatty tissues until the 
rectum lay wholly exposed except for its posterior 
attachments, the mesorectum and the rectococcygeus 
muscle. These attachments are firm and should be 
cut free with the scissors rather than torn away by 
blunt dissection, because tugging or dragging upon 
the sacral sympathetics increases the shock of the 
operation. 

The rectum was now grasped in the left hand, the 
fingers working down behind sought the attachments 
and the curved scissors in the right hand clipped 
each as met ; thus quickly cleaning out the hollow 
of the sacrum, taking with the mass all fat and 
lymphatics. By this technic the whole field of 
operation was always in sight, and the excision 
quickly and completely accomplished. (Fig. 4.) 
There was no dragging on the mesentery while 
trying to find an evasive brand that prevented 
prolapsing of the tumor. Traction on the mesen- 
tery while dissecting out the neoplasm causes much 
shock. 

The tumor being removed, all bleeders were 
ligated and the oozing controlled with a few hot 
compresses. Closure of the wound was afifected 
with catgut sutures, uniting the post cervical gap. 
When the levator ani muscle and the fascias were 
reached the clamps holding the muscles on either 
side were drawn together and the severed muscle 
united with mattress sutures of No. 2 catgut. Below 
this level the w^ound was closed with deep sutures. 
Drainage was provided from Douglas pouch into 
the vagina and also from the hollow of the sacrum 
out at the perineum. 

30 North Michigan Avenue. 



COLON INJURY IN NEPHRECTOMY. 
By Weller Van Hook, A. B., M. D., 
Chicago. 

The sigmoid and the splenic flexures of the colon 
are not far from the surgical route to the left kid- 
ney. The retroperitoneal tissues about the kidney 
may become agglutinated to the bowel and may hold 
the colon down near the kidney. If the kidney 
becomes enlarged or sacculated it may contact the 
splenic flexure. In such a case injury to the colon 
may take place during an operation on the kidney. 

Case. — A patient with chronic and acute intes- 
tinal obstruction came under observation a few 
months ago. She was so distended, poisoned, and 
weak that a cecal fistula had to be made to give 



temporary relief. The history included the state- 
ment that a Polish surgeon had removed her left 
kidney aboi t two years before, and that a fecal 
fistula had )een left. This fistula gave relief from 




Fig. 1. — ^After Hildebrandt. Note that the splenic flexture re- 
treats from the anterior part of the abdomen and rests almost upon 
the kidney. A, transverse colon; B, beginning of jejunum; C, 
splenic flexure; D, cecum; E, bladder; F, rectum; G, sigmoid flexure. 



discomfort when patent, but, when it closed, great 
distress from bowel distention occurred. On the 
occasion when she was seen with Dr. Beseler, who 
called me in the case, she suffered from acute in- 
testinal obstruction apparently due to scars about 
the bowel at the site of the old nephrectomy. 
After the patient had entirely recovered from the 




Fig. 2. — The point of almost complete occlusion of the colon is 
seen; and above is shown the arrangement of the coils of the colon 
so that the fecal current is accommodated after anastomosis. 



intestinal obstruction, attack was made upon the 
real cause of trouble. The old nephrectomy wound 
was opened and extended downward, when it was 



24 



KNOPF: THE SOUL OF THE CONSUMPTIVE. 



[New York 
Medical Journal. 



easily seen that the splenic flexure was bound down, 
damaged and occluded as suggested in the picture. 
The bowel evidently had been caught in the clamp 
used to compress the kidney stump. Since there 
was no active disease at the site of occhision, noth- 
ing was done at the immediate point of injury, but 
the bowel above was joined by anastomosis to the 
descending colon below. This procedure, colocol- 
ostomy, resulted in complete and satisfactory re- 
establishment of fecal circulation. 

CONCLUSIONS. 

1. Injuries of the left colon take place readily 
when left nephrectomy is practised. 

2. Nevertheless, damage to such an extent that 
intestinal obstruction occurs must be rare and the 
result of gross carelessness. 

3. In acute intestinal obstruction life is less likely 
to l)e sacrificed in most cases if a fecal fistula is 
established at the cecum for a few days. This tides 
the patient over the toxic period. 

4. Colocolostomy satisfactorily reestablishes the 
fecal current, making it unnecessary to work at the 
site of scar contraction where wound infection from 
the bowel can occur so easily. 

31 North State Street. 

THE SOUL OF THE CONSUMPTIVE. 

A P-lca for Justice* 

By S. Adolphus Knopf, M. D., 
New York. 

We all know something about the physical suffer- ' 
ings of the consumptive caused either by his tuber- 
culous lungs, throat, or other organs which may 
have been attacked by the germ of the disease. 
We have heard his nerve racking cough, his hoarse, 
often scarcely audible voice, observed his gasping 
for breath, and know that he has pain in his chest, 
even when at rest, or on swallowing food if his 
throat is involved. We have felt his feverish hands, 
noticed his parched tongue, and sympathized with 
him because of these and many other distressing 
symptoms indicative 'of physical suffering. 

I (|uestion, however, if many of us fully realize 
what the consumptive, rich or poor, young or old, 
suffers in mind and soul, beside his physical pains. 
We assert that tuberculosis, which is only another 
name for consumption, is a preventable disease. The 
late King Edward of England once said to a delega- 
tion of tuberculosis workers: "If, as you say, tuber- 
culosis is preventable, why not prevent it?" This 
same question the rich or well to do consvmiptive 
may have asked himself, or may be still asking it. 
But before answering, I should like to ask him 
what he ever did in life to prevent the disease 
before becoming ill himself? Perhaps he never 
thought of his employees or of the thousand others 
who were working in ill ventilated workshops with 
no dust consumers, and living in dark and dreary 
tenements or insanitary individual dwellings where 
tuberculosis had become a house disease. Perhaps 
he never thought of having the men and women 
working for him examined periodically so that any 
case of tuberculosis among them might be detected 

•Address delivered by invitation before the Christmas .Seal Cam- 
paign of the New York Tuberculosis Association, December 1, 1920. 



and the other still healthy employees prevented 
from becoming infected. It may never have oc- 
curred to the rich employer, now a consumptive, 
that when still at the head of his business, he should 
have seen to it that any one of his employees who 
had been found afflicted was cured by being taken 
care of at the right time and in the right place, and 
not as Dr. Pryor so well says, at the wrong time 
and in the wrong place, when it was too late to 
accomplish a cure. 

Such thoughts will cause the well to do consump- 
tive suft'erings which are difficult to describe. 
While his physical pains and discomfort, thanks to 
his abundant means, can be lightened, this suffering 
of the soul, because he failed to do his duty toward 
his fellowmen, many of whom have now become 
his fellowsufferers, becomes more intensified as" the 
disease progresses. It is all the more present in 
his mind because he knows that the suffering of 
the .poor consumptive in both mind and body is a 
tliousand times more intense than his own. The 
physical sufferings are alleviated in his case by a 
sojourn in a health resort, a costly private sana- 
torium, or a luxurious home where the sanatorium 
treatment can be carried out under the watchful 
care of a skilled specialist; the poor consumptive, 
on the other hand, because of lack of sanatorium 
facilities, often has to remain at home and there, 
because of limited means, is deprived, if not totally 
to a large degree, of the comforts and facilities 
which help toward the cure. The well to do con- 
sumptive may have the assurance of a cure after 
a reasonable length of time, but the poor consump- 
tive is far from having this absolute assurance. 
He counts the days to the time when he hopes to 
be able to work and be no longer a burden to his 
family and the community. 

I am free to confess that I do not share at all 
in the opinion of a certain tuberculosis specialist 
and author who, in his recent textbook, gives the 
following characterization of the tuberculous patient : 
"The consumptive becomes egotistical and ego- 
centric. He is interested in the welfare of but one 
person — himself — to the exclusion of all who have 
depended on him before. He will eat costly food 
while his children starve ; he will make unreasonable 
demands on his relatives and friends and show no 
gratitude. . . . The ascendance of selfishness plays 
the most important role in the molding of the men- 
tal traits of the tuberculous." I have always looked 
on this statement as a veritable libel upon the char- 
acter of the consumptive, if indeed he may be set 
apart as having special characteristics because of 
his disease. An experience of over twenty-five 
years among the tuberculous poor, in humble cot- 
tages and dreary tenements, in pul)lic sanatoria and 
hospitals, has convinced me that the very contrary 
is characteristic of the heart, mind, and soul of 
the consumptive. How many times have I heard 
some one among them .say: "If I only were rich, 
doctor, I would know how to solve the tuberculosis 
problem." I never refuse to listen to their schemes, 
which are sometimes fantastic, but never egotistical. 
They think of saving others even when realizing 
that they cannot be saved themselves. 

Tuberculosis, i)articularly of the pulmonary type, 



January 1. 1921.] 



KNOri-: THE SOUL OF THE CONSL'MI'Tnii. 



25 



attacks, principally, men and women l)ft\vccn the 
ages of eighteen and thirty-five — the golden age of 
youth, of love, of aspiration, of hopes, and dreams. 
The most important events are often crowded into 
these fifteen to twenty years which are usually 
known as the best in life. To understand their 
feelings, one must have had th.e sad duty of inform- 
ing a young person with all life before him of the 
fact that he is tuberculous, that he must for the 
time being abandon all work and devote a year and 
perhaps two to getting well. The young person to 
whom such a declaration has been made, apparently 
acts as if he or she believed in the doctor's assurance 
of the curability of the disease, but the old fashioned 
idea that tuberculosis is incurable still lurks in the 
minds of the masses, and doubts of the curability, 
in spite of the doctor's a.ssurance, will arise in the 
mind of the newly discovered tuberculous invalid. 
But even if he is of an optimistic disposition and 
believes in tlie favorable prognosis in his case, if 
he is poor or only of moderate means, has an old 
father or mother, an invalid brother or sister, or 
wife and children dependent upon him, his sufifering 
of soul begins right then and there. He is worried 
because he cannot provide for them, and not only 
does the thought haunt him that his wife and chil- 
dren may suffer for want of food, raiment, and 
even shelter, but in addition to this there is often 
in the mind of the conscientious consumptive a 
fear that he may give the disease to some one near 
and dear to him in spite of the precautions he tidies 
to take. The social workers and auxiliaries of 
such societies as are represented here tonight, con- 
sider it always as one of their most important tasks 
to relieve the anxiety of the patient concerning his 
family by providing amply for their needs. The 
consumptive's fears that he may be the source of 
tuberculous infection can only be counteracted by 
education imparted by the physician and the nurse. 

Thus we see that the sufiferings of the consump- 
tive, rich or poor, man or woman, are not confined 
to the body, and alas ! this is also true of the chil- 
dren. Tuberculotis disease in children is most fre- 
(|uently situated in the joints and bones, and abso- 
lute rest of the afflicted members of the body often 
])ecomes an urgent necessity; in other words, the 
child is compelled to remain still, often even con- 
fined to bed. He cannot play as other children do. 
When others romp around in field, in garden, or on 
the streets, as they must do in our great cities for 
lack of playgrounds, he can only look on. He may 
not even be able to enjoy school life as others do. 
and he lacks the companionship and comradeship 
which makes child life so happy and delightful. 
This tuberculous child suffers as much in mind and 
soul, and perhaps more so, than in body. 

Lastly, there is that strange disease known as 
phthisiophobia, with which not the tuberculous but 
the nontuberculous are afflicted. It is an exag- 
gerated fear of the presence of anyone afflicted with 
pulmonary tuberctilosis. This tuberculosis phobia, 
or phthisiophobia, has caused and is causing more 
suffering to the consumptive than it is possible to 
imagine. People will object even to the presence 
of tuberculosis sanatoria and tuberculosis hospitals, 
and yet the safest place not to contract consumption 



is in \n>\ such an institution, where ilie greatest 
j)ossible care is taken with the expectoration, which 
is virtually the only source of infection. Peoi)le 
will not employ even the recovered consumptive and 
some are afraid to touch him or associate with him. 
Tuberculosis is indeed a public menace, and with 
the prevalence of the disease we cannot be certain 
that some day we ourselves or someone very dear 
to us may not be stricken with it. And yet, there 
is no more danger in association with the consump- 
tive who is conscientiotts in the disposal of his 
sputum than with any well person ; therefore let us 
treat him kindly and considerately. 

In speaking above of the rich consumptive as un- 
mindful of his obligation toward his fellow suffer- 
ers and fellowmen in getaeral, I do not wish to be 
understood as implying that this is always the case. 
There are now any number of corporations and 
em])loyers of large bodies of men and women who 
do look after the health of their employees, and it 
has been my rare privilege to treat some wealthy 
tuberculous patients whose hearts ached for. the less 
fortunate sufferers among the poor and who gave 
freely of their worldly goods. I know of a number 
of instances among those who were hopelessly ill 
where a large part and sometimes even the entire 
fortune was left for the care of the consumptive 
poor. They often suffer in soul because of their 
inability to do more, knowing by personal experi- 
ence how much is needed to combat this disease 
among the i)oor and those of moderate means. 

And now, having told you of the suffering of the 
soul of the tuberculous rich and poor, young and 
old, I come to jjlead for them — not for mercy, not 
for charity, but for justice. Let the employer do 
justice to his employees by periodical examinations 
for tuberculosis and providing proper sanitation for 
factory, workshop, and store. Let him see that the 
worker found to be tuberculous receives proper and 
timely treatment. Let the municipality of cities, 
towns, and villages see to it that there are no in- 
sanitary dwellings, and that such other in.sanitary 
conditions which may predispose, to tuberculosis 
may be done away with in the community. Let 
every community provide sanitary school buildings 
and see that the curriculum is such that the mental 
training of the child is not pushed to the neglect 
of its physical development. 

The New York Tuberculosis Association, in co- 
operation with the city's Health and Public 
Welfare Departments and by its educational work, 
teaches all this to our own and other muni- 
cipal authorities, employers, and school boards, 
and tries to prove to these latter why there should 
never be a public or private school of any size with- 
out some open air classes. To the people at large 
it teaches that tuberculosis is a preventable and 
curable disease. In its clinics thousands of men, 
women, and children are annually examined, and 
thus many cases of tuberculosis are discovered at 
the right time and the association sees to it that 
the patient is properly cared for. By its auxiliaries 
to the tuberculosis clinics, it gives financial relief to 
tuberculous families in distress. By its model sani- 
tary workshops, its vocational training, and its 
employment bureau it enables the tuberculous in- 



26 



LONDON LETTER. 



[New York 
Medical Journal. 



valid, or the recovered tuberculous patient, to make 
an honest living without running the chances of a 
relapse. 

Bearing in mind that the protection of children 
from tuberculous disease and the cure of those 
already afflicted is, after all, the essence of the solu- 
tion of the tuberculosis problem, this association 
has started a health centre for babies and parents 
so that there shall be prenatal care, infant welfare 
work, care of the children during their preschool 
age, preventoria for children strongly predisposed 
to tuberculosis, etc. In short, all that can humanly 
be done to prevent tuberculosis and to cure those 
afflicted with it, this association and one thousand 
others throughout the United States are trying to 
do. It appeals for financial help and encourage- 
ment ; it appeals to all able to help in this great 
crusade which has for its purpose the lessening of 
the sufferings of mind, body and soul, and rendering 
happy, healthy, and useful thousands of our fellow- 
beings who otherwise might be doomed to be a 
burden to the community and to a lingering death, 
accompanied by indescribable suffering. The asso- 
ciation appeals for justice to the cause of the tuber- 
culous sufferers who contracted the disease by no 
fault of their own. It is our duty to help them ; 
let us hasten to embrace this opportunity for service 
to God, country, and our fellowmen. 

16 West Ninety-fifth Street. 



LONDON LETTER. 
(From Our Own Correspondent.) 

Treatment of Patients on the Borderline of Insanity— Care 
of the Mentally Deficient — Medical Education in _ Great 
Britain — Cancer Research— Clinics for Mental Diseases. 

LoxDON, November 30, 1920. 
The treatment of insanity is now conducted upon 
more intelligent lines by far than was formerly the 
case. It is recognized that certain forms of men- 
tal disorder, whfch not long ago were regarded as 
hopeless, are amenable to proper treatment. Of 
course, it is largely a question of correct diagnosis 
and treating the disease while in the incipient stage. 
It is only within comparatively recent times that 
any provision has been made for the obsen-ation 
and treatment of what are known as borderline 
cases. In the Ministry of Health bill introduced 
a short time ago in the House of Commons, are 
new legislative proposals concerning the treatment 
of incipient mental disorder. Clause 10 of this 
bill deals with the treatment of incipient mental 
disorders and contemplates that a person thus suf- 
fering may be received in homes, institutions, or 
houses. An individual may be dischaiged from 
one of these places if he delivers to the superin- 
tendent or other person having charge, or sends by 
post to the Minister of Health, a notice in writing 
that he desires to be discharged. This clause was 
sharply discussed by a committee of the House of 
Commons, which addressed itself to the problem 
of combining treatment and freedom of personal 
action on the part of the patient. In accepting an 
amendment that the notice to the minister should 



be one of forty-eight hours, Dr. Addison, Minister 
of Health, said he wanted to have these institutions 
as free as possible for the people to go out. The 
forty-eight hour limit was necessary in the case of 
a letter sent through the post. Lieutenant Colonel 
Raw proposed an amendment to provide that in 
the case of the mental incapacity of a patient, the 
consent might be given by the nearest relative. 
This was opposed on the ground that its adoption 
might lead to abuse. A husband, for instance, 
anxious to get rid of his wife, might quarrel with 
her, say she was mentally unfit, and have her 
placed in a home against her will. Dr. Addison 
said if the clause was not amended in the way 
suggested, it would shut out a large number of 
shell shock cases where the sufferers in the early 
days were not competent to sign their names. He 
admitted that the acceptance of the amendment 
might lead to an increased opportunit}' for scandals 
to arise. Personally he would vote for the amend- 
ment which was rejected. The clause with the 
amendment that the notice to the minister should be 
one of forty-eight hours was agreed to. 

* * * 

Under the auspices of the Central Association 
for the Care of the Mentally Deficient, a conference 
on mental deficiency was opened on November 25th 
last at Church House, Westminster. Among the 
speakers was Sir George Newman, chief medical 
adviser of the Ministry of Health, who said, in part, 
that the responsibility of the State lay in the duty 
of finding out mentally defective children. If 
money was not spent on their training it would be 
spent because they would become a charge on the 
State. The child's training must consist, not in 
making him capable of passing an examination, l)ut 
of converting him or her into a good citizen. A 
resolution was passed urging legislation to enable 
local educational authorities and authorities under 
the Mental Deficiency Act to combine in the pro- 
vision of institutions. 

The problem of treating mental disorders in their 
incipiency and preventing insanity as far as pos- 
sible, and of so training mental defectives that they 
may become useful rather than harmful, is one 
that confronts every country of the world. It is 
also increasing in its gravity. Unfortunately, men- 
tal defectives are numerous in all civilized countries, 
and are a public menace. The result of legislation 
in Great Britain to offset the evil effects of mental 
deficiency is a step in the right direction, and will 
doubtless be watched by the governments of other 
countries with the closest interest. 

* * * 

The matter of medical education in this country- 
was made a subject for discussion at the meeting 
of the British Medical Council, which opened on 
November 23rd, under the presidency of Sir 
Donald Macalister. Introducing a report on pro- 
fessional education before the council on Novem- 
ber 25th, Dr. John Yule Mackay, chairman of the 
education committee, said that the undue stress 
\vhich was laid on the test by written examination 
frequently repeated was a weakness and source of 
danger in the British educational system. The habit 



Januiiry 1. 1921.] 



LONDON LETTER. 



27 



of judging progress in study by a method which 
demanded severe but spasmodic eiforts directed 
toward the repetition of details often unimportant, 
and usually only partially understood by the pupil, 
was unfortunately growing and tended to obscure 
the true purposes of education. In medicine today 
the exigencies of the examination tended to dom- 
inate both teaching and study. 

It has long been recognized by many of those 
best qualified to judge that the written examination 
in all spheres of education has been abused. Per- 
haps the folly of paying too great attention to 
the written examination has been most in evidence 
in medical education. A brilliant man, one who 
imbibes his facts easily, will cram for a written 
examination, pass with flying colors, and forget 
a good deal of this undigested matter in a short 
time. The written examination does not by any 
means always constitute a reliable test of a man's 
knowledge, nor, it must be added, are the questions 
asked calculated in many cases to yield the best 
results in tlie long run. As Dr. Mackay said, un- 
important details are frequently pushed into the 
foreground while really essential points are left 
severely alone. 

The question of written examinations in medi- 
cine and surgery is one that needs discussion and 
consideration in all countries and one upon which 
valuable reports might be composed. 

:|: * * 

At the home of the Medical Society of London, 
Professor J. B. Farmer, of the Royal Society of 
Science, South Kensington, lectured on Some 
Biological Aspects of Disease on the evening of 
November 25th. He urged a more comprehensive 
and thorough investigation of the cancer problem 
than had so far been attempted. He asked. 
Were the people of Great Britain prepared to go 
on watching the daily ravages of an unsparing foe 
without doing everything that was hinnanly pos- 
sible to check its course? It appeared to the 
speaker that the full magnitude of the task had 
not been sufficiently realized. A dozen or more of 
the first rate men attached to research in the diflfer- 
ent relevant branches of science should be working 
in collaboration, and they ought to be provided 
with the means of attracting to their laboratories 
a number of able research students. 

Professor Farmer is perfectly right in criticising 
the attitude of the British public toward scientific 
research. The average man here regards the ques- 
tion with contemptuous indifiference, and will not 
put his hand into his pocket to assist the advance- 
ment of research. He does not understand its 
value and, therefore, through ignorance, depreciates 
its usefulness. He requires to be educated himself. 
As is truly said in an editorial in the Medical Press 
and Circular for November 24, 1920, the British 
people grudge the expenditure of public money on 
science, and, despite the lessons of the war, that 
grudging is being actively pursued. Doubt may be 
felt whether Great Britain will ever understand that 
a nation which lays itself out to develop science 
places itself in the position of cultivating an un- 
limited field of wealth. The discoveries of science 



must always lead the way in the advancement of 
industrial occupations. But so it is that science 
is "starved," starved by the fear of money being 
spent upon that which will produce unremunerative 
results. 

This statement emphasizes the point that the 
British lack of appreciation of scientific research 
and of medical scientific research in particular is 
largely due to a want of comprehension of the 
subject in all its bearings. If a nation is not gen- 
erally healthy it cannot long be prosperous, as a 
healthy nation has a manifest advantage over one 
that is handicapped by disease and invalidity. The 
British public must be educated to understand this 
point of view before money will be given freely 
in aid of medical research. However, among the 
persons who should understand the situation, the 
presumably educated rich, there is displayed a 
niggardliness toward contributing to assist the 
advancement of scientific research which is aston- 
ishing. In America money is poured out without 
stint to aid in the progress of science. The idea 
appears to be grasped in America that money spent 
on science and on medical science is money well 
spent. It comes back with compound interest. To 
lay bare the secrets of disease and to prevent its 
occurrence is only possible with the assistance of 
medical research. The country that is healthy and 
has made the most intelligent use of science in 
all its forms will easily be the most prosperous and 
contented. Until the mass of the inhabitants 
acquire a conception and appreciation of the value 
of science, it cannot keep abreast of the countries 
that do these things. 

* * * 

The problem of dealing properly with mental 
disorders has been referred to already in this letter 
at some length. However, as it is an extremely 
important subject, it will not be superfluous to 
comment upon other aspects of the matter. In 
Great Britain only one hospital, the Lady Chichester 
Hospital for Women and Children at Hove, Sussex, 
specializes in all forms of nervous and mental 
breakdown in their early stages. This hospital has 
just published a short survey of its work for the 
past fifteen years. It states that experience gained 
in the hospital strikingly confirms the arguments 
which the leading mental specialists are now urging 
in favor of establishing clinics for the treatment 
of such diseases in connection with the general hos- 
pitals. Under the present system no hospital treat- 
ment is provided for nervous and mental patients 
until they have reached the certifiable, and, there- 
fore, in the majority of cases, the incurable stage. 
What is urgently needed is that sufferers from these 
diseases should have exactly the same prompt and 
easy access to treatment as the sufl^erers from any 
physical disease. The treatment pursued at the 
hospital was most successful, and it is stated that 
it has a waiting list five times more numerous than 
the patients under treatment. The psychopathic 
ward as known in America is unknown here, but 
great interest is now being evinced in the question, 
and it appears certain that some will be established 
in general hospitals in the near future. 



Editorial Notes and Comments 



NEW YORK MEDICAL JOURNAL 

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and the Medical News 

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NEW YORK. SATURDAY, JANUARY 1, 1921. 



SEASON'S GREETINGS. 
To our readers, contributors, advertisers, and 
friends with whom we have spent the none too 
short nor untroubled year, we extend our warm- 
est greetings. From the signs on every hand the 
immediate future seems none too lacking in the 
demands it will make upon us to face stressful 
situations. It is only by recognizing things as 
they are and not as we would have them that we 
shall be able to meet them whole heartedly and 
unafraid. We extend our greetings and our hand 
to you all and trust that we can go together 
toward the goals of progress with the knowledge 
that striving makes strength. We thank you for 
your cooperation in the past. It has made the 
struggle worth while. We trust that we may act 
as an inspiration and make your task the more 
worth while and easier of fulfillment. Let us 
meet the New Year with strong hearts, with be- 
lief in ourselves and one another. 



MEDICINE AND AGRICULTURE. 
Under the term agriculture, doctors are now to 
study all that pertains to foods and breeding and 
to drug production. The farmer, the veterinary, 
the botanist, the chemist, will henceforward find a 
place at medical meetings, for the gentle cow, the 
frolicsome lamb, the silvery fish may harbor disease 
in life and give it to man when dead. Plants them- 
selves have foes, which make them enemies of man. 
We pay highly for imported drugs which flourish 
in our field. Epidemics destroy our stocks, thereby 



the price of food is raised and people suffer in 
health. So that the whole science of liealing seems 
likely to resolve itself into the great question of 
cooperation of the entire scientific world, for, truly, 
no one body can be rejected without loss to the 
whole. 

An Indian doctor draws attention to the further 
knowledge and cultivation of Indian drugs, saying 
that although the British Government has acted 
wisely in appointing directors, yet it would have 
been better to have selected some native medical 
practitioners who thoroughly know the plants and 
know also their Ayurvedic materia medica. India 
abounds in medicinal plants, but only comparatively 
few are really known, and yet are used empirically 
as household remedies. Every step and process 
should be recorded in the scientific journals, meri- 
torious work receiving reward, and suggestions 
invited. 

Veterinaries in foreign lands are forging ahead 
guarding our food supplies by scientific investiga- 
tions. One member of the Royal College of Veter- 
inary Surgeons has been to South Africa, inoculat- 
ing Mbosi cattle for rinderpest, and found laminitis 
general. Tlie animals became lame, had no milk, 
and wanted to lie down. Sir Arnold Theiler has 
]>r()ved that Crotolaria burkeana is responsible. The 
veldt is rich in leguminous plants, and game of all 
kinds assemble for feeding during the dry season. 

Even camels are being studied, as 86.52 of those 
on service in Mesopotamia died, but it must be 
remembered that special knowledge is required and 
few of the keepers had ever seen a camel outside 
a zoo. Two men in India are endeavoring to fight 
the Syngamus laryngeus in Indian cattle and buf- 
faloes. The parasite is foimd attached to the 
interior of the larynx; there are symptoms of cough- 
ing, loss of condition, and speedy death. Ten or 
twelve pairs of worms on the mucous membrane 
of the larynx were found postmortem. 

The chemists and liotanists who were in govern- 
ment service during the war are now making wide 
voyages in little explored places to gather and test 
proposed substitutes. One man we know went from 
London away to the forests of Buenos Aires, 
another to the remote parts of South Africa. 

The work of the bacteriologist is still conquering. 
Slowly, slowly, the unknown evils which devitalize 
the grand tree and the ponderous buffalo, man in 
his prime, the cradled baby, are discovered, and will 
utterly be destroyed when the great army of co- 
operative research is no longer merely an idea.. 



hiiiuaiN 1. 1921. J 



EnirORIAL AKTICI.liS. 



29 



TILANSFUSION OF HLC )()!). 

It is now a truism to state tiiat transfusion of 
blood established its value during the war. It cer- 
tainly did so, and, of course, new and more effective 
methods of carrying out the x^rocedurc were evolved. 
Although no method can be said to be unsusceptible 
of improvement, it can be stated unreservedly that 
saTisfactory methods of blood transfusion have been 
thought out and practised. At a meeting of the 
Edinburgh Mcdico-Chirurgical Society, held on 
November 4, 1920. Mr. J. M. (Jraham read a ])aper 
(in transfusion of iilood, basing his observations on 
seventy-five cases. He pointed out that the first 
question is the choice of a suital)le donor, and that 
in all cases, except in newborn infants, jirelim- 
inary tests must be done to preclude the risk of the 
patient's serum hemolyzing the donor's corpuscles. 
This is a very important point and should be ascer- 
tained definitely before transfusion is commenced. 
As hemolysis is always preceded by agglutination 
of the corpuscles, the patient's serum is tested to 
find out if it agglutinates the donor's corpuscles. 
If it does not do this the donor is satisfactory. 
There is no need to describe the technic of this test. 

As for the method of transfusion, Graham agrees 
with the majority of those who have had experi- 
ence, that the simple.st method is hy the. use of a 
solution containing such a salt as .sodium citrate, 
of which two per cent, is required to prevent clot- 
ting. He uses a three and eight tenths per cent, 
solution, which, when diluted with nine volumes 
of blood, gives a strength of thirty-eight hundredths 
per cent., thus allowing a small margin on the 
right side. Graham thinks this solution is quite 
as effective as whole blood in cases of hemorrhage, 
but there is a greater tendency for a reaction to 
occur. He does not recommend the direct arm to 
arm method, as it is difficult and. necessitates the 
sacrifice of a radial artery, and also the volume can- 
not be measured. In his opinion the chief indica- 
tions for transfusion are serious hemorrhages, espe- 
cially in the absence of complications, and when the 
bleeding point can be controlled. In hemorrhages 
with slight shock it is also indicated, and also as 
a preventive of shock in operations on anemic 
patients. In cases where shock is marked, results 
are unsatisfactory. In chronic anemia, results are 
doubtful ; but when other treatment has failed and 
there is no discoverable primary disease to prevent 
recovery, it should be tried. In malnutrition of in- 
fants, especially where the infant is reduced to the 
stage of collapse, there is often striking benefit seen, 
but results as a whole are doubtful. 

Perhaps the best results from transfusion are 
witnessed in pernicious anemia. Graham states that 



out of tliirlx -eight ca^es there was delinile imi)ri)\e- 
menl in twenty-one. a very satisfactory outcome. 
Results were better when whole blood was given. 
In these cases transftision was recommended because 
the symptoms were progressive or stationary, in 
spite of the usual treatment, and because the patients 
were in a critical condition. The signs of imjirove- 
ment lasted a variable time, but the blood counts 
never returned to normal, and the expectation of 
life for a few months was small. The chief value 
of transfusion in this disease is that it might stimu- 
late the marrow^ in stich a way that a patient toler- 
ates arsenic better and improves until a subsequent 
relapse occurs. 

In the main Graham's views are in accord with 
others who have had a good deal of experience 
of transfusion during the war. It should be borne 
in mind that Robertson, of Toronto, was a pioneer 
in evolving new methods of blood transfusion, and 
that Primrose, also of Toronto, did much good 
work in the same direction. Transfusion was one 
of the surgical procedures which was greatly ad- 
vanced through war experience. Valuable knowl- 
edge was gained which will undoubtedly be put to 
good u.se. and especially so in industrial surgerv. 



PHYSICIAN AUTHORS: DR. JOHN 
BROWN 

Of all the literary canines that go yapi)ing and 
yelping through the pages of literature, right away 
back to the m}thical hounds which Diana kennelled 
on Olympus and down to the present day assortment 
of magazine and twelvemo collies and terriers, none 
is more famous that Dr. John Brown's old, grey and 
brindled mastiff, Rah, "as big as a Highland bull" 
but much more lovable. The story of Rab and His 
Friends is known wherever English is spoken and 
holds its own as one of the finest dog stories ever 
writteti. There are many who would call it the 
finest. It is part of what Andrew Lang called "the 
light but imperishable literary baggage" which Dr. 
Brown left to posterity, for his fame greatly ex- 
ceeds the measure of his literary output. It is built 
upon a few essays and sketches, but chiefly it rests 
upon the story of Rab. Rab and His Friends was 
published first in 1859. Brown wrote it between 
twelve and four of a summer morning, it is said. 

Ye stapped your pen into th' ink 
.\n' there wa.s Rah, 

as Robert Louis Stevenson wrote in his poem. "To 
Dr. lohn Brown." Stevenson was one of the many 
great ones of the earth who have been fond ol 
Rab. It is doubtful if any other short story ever 
elicited as much praise from so many eminent ad- 
mirers. Their tributes would fill a large book. 



30 EDITORIAL 

Dr. Brown's small literary output was due to 
the fact that most of his life and energy were given 
over to the practice of medicine. He was the most 
eminent physician of Edinburgh of his day, and 
"thoroughly devoted to his profession." J. Taylor 
Brown, writing in the Dictionary of National Bi- 
ography, points out that it is doubtful whether 
Brown, for all his wide culture, would ever, but 
for his love of his profession, have been induced to 
appear before the world as an author. His first 
volume, Horce Subscciva is almost exclusively de- 
voted to subjects bearing on the practice of med- 
icine, such as the importance of the wide general 
culture of a physician, the distinction to be always 
kept in mind between medicine as a science and 
medicine as an art, the necessity of attending to 
Nature's own methods of cure and leaving much 
to her recuperative powers rather than to medical 
prescriptions, and, in general, the value of presence 
of mind in a physician. 

Horce Subscciz'cc was one of three volumes that 
comprise Dr. Brqwn's literary output. We are told 
that editors and publishers had to importune him to 
write, and that his answer invariably was that one 
should not venture to publish anything "unless he 
has something to say and has done his best to say it 
right." "Herein lay the secret of his writing so little 
and of the surpassing charm of what little he did 
write," says Chamber's Cyclopedia of English Lit- 
erature. "Dogs, children, old world folks, friends 
gone before and Lowland landscapes — these were 
the subjects he wrote on best. Humor is the chief 
feature of his genius — humor with its twin sister, 
pathos. We find them both at their highest per- 
fection in his sketches Rab and His Friends and 
Pet Marjoric. Writing of nothing that he did not 
know, he wrote of nothing he did not love, at least 
of nothing that he did not greatly care for — hence 
both the lucidity and the tenderness of his essays. 
They rank with Lamb's, and with Lamb's alone in 
the language." 

In recent months there has been renewed interest 
in his sketch of Pet Marjoric, due to the somewhat 
sudden craze for the writings of child literary prod- 
igies that has sprung up since Daisy Ashford burst 
in on an unsuspecting public with The Young Vis- 
iters. Pet Marjorie, whose full name was Marjorie 
Fleming, before her death in 1811 at the age of 
eight, had written reams of journals and poems, in- 
cluding a two hundred line epic on Mary, Queen of 
Scots. She and Sir Walter Scott were great chums. 
Her biography, written for the Dictionary of Na- 
tional Biography by Sir Leslie Stephen, is, as Sir 
Leslie said, "probably the shortest to be recorded in 
tliese volumes, but she is one of the most charming 



ARTICLE.S. [New York 

Medical Journal. 

characters." Equally charming is the essay Brown 
wrote of her. 

Dr. Brown was born at Biggar, Lanarkshire, 
Scotland, on September 22, 1810, and died in Edin- 
burgh on May 11, 1882. He attended a private 
school at Edinburgh from 1822 to 1824, then spent 
two years at the Edinburgh high school, after which 
he attended Edinburgh University, where he began 
the study of medicine in 1827. From 1828 to 1833 
he was apprenticed to Dr. James Syme, one of the 
most famous surgeons of his day, and obtained his 
medical degree at the university in 1833. He spent 
the rest of his life in Edinburgh in the practice of 
medicine. In his medical capacity he is said to have 
been remarkable for his close and accurate observa- 
tion of symptoms, his skill and sagacity in the treat- 
ment of his cases and his conscientious attention to 
his patients. "He was a man of rare sweetness of 
disposition and charm of manner," says Andrew 
Lang. "I have never known any man to whom 
other men seemed so dear — men dead, men living. 
He gave his genius to knowing them, and to making 
them better known, and his unselfishness thus be- 
came not only a great personal virtue, but a great 
literary charm." 



THE TUBERCULOSIS PROBLEM OF TH^ 
PRESENT DAY. 
Because before the war the tuberculosis mortality 
had been on the decrease in nearly all civiHzed 
countries, and particularly in our own, there is no 
doubt that its present increase throughout Europe 
and to some extent also in our own country is a 
consequence of the war. In Central Europe the 
situation is appalling and Mr. Hoover is asking 
for $33,000,000 to feed the 3,500,000 starving 
children, many of whom, by reason of underfeeding 
and privation, are already tuberculous or will be- 
come so if succor does not come soon. Mr. Hoover 
wishes to devote $10,000,000 of the $33,000,000 to 
medical relief. It is our earnest hope that this good 
and great man will get all he asks for to accomplish 
what may be considered the greatest humanitarian 
work ever done by the American people. However, 
we must not forget that here, too, we have a tuber- 
culosis problem toward the solution of which we 
must devote our energies. In the United States 
it is perhaps not so much malnutrition and want 
of proper clothing as the congestion resulting from 
lack of housing facilities in our large cities which 
is responsible for the increase of tuberculosis. The 
congestion today in our own city, particularly in the 
tenement house districts, is something fearful. 
Total ignorance of sanitary regulations among a 
large class of the population in the congested dis- 



January 1, 1921.] 



EDITORIAL ARTICLES. 



31 



tricts adds to the spread of the disease. Aside from 
this, we are in midwinter and the problem of un- 
employment on an unprecedented scale is slarinj;- 
us in the face. 

In Dr. Knopf's article, entitled The Soul of the 
Consumptive, which appears in this issue, a graphic 
description is given of the mental sufferings of con- 
sumptives, the rich and poor alike. When we add 
to this the physical sufferings of the tuberculous 
invalid, it certainly must be obvious that there is 
much work to do yet for the housing, general social 
betterment and education of the masses. The New 
York Tuberculosis Association is in great need of 
funds to do its work in cooperation with the health 
and public welfare departments of this city. This 
association helps to maintain our tuberculosis dis- 
pensaries, has a model sanitary workshop for voca- 
tional training, maintains a health centre for babies 
and parents, coordinates other charitable institutions 
in relief work, and gives financial aid to families in 
distress. The New York Tuberculosis Association 
has for its president Dr. James Alexander Miller, 
for its secretary Dr. Nathan E. Brill, for its treas- 
urer Mr. Thomas W. Lamont, and for its director 
, Dr. John S. Billings, with offices at 10 East Thirty- 
ninth Street, New York City. On the board of 
directors are such distinguished medical and social 
workers as Dr. and Mrs. Hermann M. Biggs, Dr. 
John W. Brannan, Dr. Royal S. Copeland, Dr. 
Haven Emerson, Mr. Homer Folks, Dr. Lee K. 
Frankel, Mrs. W. E. S. Griswold, Mrs. James E. 
Newcomb, Miss Blanche Potter, Dr. George M. 
Price, Mr. Lawson Purdy, Mr. Fred M. Stein, and 
Mrs. William G. Willcox. 

The national association, of course, has a still 
greater field of usefulness than the local association. 
Besides coordinating all the state and local associa- 
tions and other agencies in the fight against 
tuberculosis, this association has a publicity bureau 
and a number of traveling exhibits, publishes a 
sanatorium directory, promotes needed federal 
legislation and health programs, and standardizes 
all forms of antituberculosis work. The work of 
the association is accomplished through correspond- 
ence, field work by staff representatives, annual 
meeting^ of sectional conferences, conduct of 
interstate campaigns, such as the Red Cross 
Christmas Seal sale, tuberculosis week movement, 
general publicity, publication of research studies, 
literature, bulletins, and, in general^ by serving as 
a clearing house for information and advice on every 
phase of the tuberculosis problem. The National 
Tuberculosis Association also publishes a most 
reliable scientific journal. A review of its Novem- 
ber number appears in our present issue, which 



speaks for itself. The name of the journal is the 
American Reviezv of Tuberculosis. The officers 
of the National Tuberculosis Association are Dr. 
Gerald B. Webb, of Colorado Springs, president; 
Colonel George E. Bushnell (retired), of Bedford, 
Mass, honorary vice-president; Dr. George M. 
Kober, of Washington, D. C, secretary; Mr. Henry 
B. Piatt, of New York, treasurer; Dr. Charles J. 
Hatfield, of Philadelphia, managing director; Dr. 
Philip P. Jacobs, of New York, publicity director; 
Mr. Frederick D. Hopkins, of New York, adminis- 
trative secretary. The board of directors is com- 
posed of leading specialists and social workers of 
nearly every State in the Union. * The office of the 
association is located at 381 Fourth Avenue. 

Any reputable physician in good medical standing 
and any layman honestly interested in the control 
of tuberculosis and is not engaged in an enterprise 
foreign to the ideals of the association is welcomed 
to membership. The dues are five dollars a year. 
Members of the association are entitled to receive 
a number of valuable publications, including the 
Journal of the Outdoor Life, a monthly magazine 
and the official organ of the association ; the Monthly 
Bulletin of the association, and various other inter- 
esting and instructive publications which are issued 
from time to time, such as Transactions, Tubercu- 
losis Directory, and various special volumes and 
studies. Members are also entitled to receive the 
American Review of Tuberculosis, at the reduced 
price of two dollars a year. 

BARBERS, EAST AND WEST. 
Dr. Arjan Das, in the Indian Medical Journal. 
deplores the fashion for cropped hair which is gain- 
ing in India. He says hair is an additional 
ornament for a rich woman, and often the only 
ornament of the poor. "In man if the hairs are 
well combed, oiled, and parted, either in the centre 
or side of head make one look like a gentleman." 
The shaving of mustache and the epilation of nasal 
hairs is bad, as they prevent the introduction of 
even minute particles of dust entering the nose. 
Worse still is the increasing practice of shaving" 
the beard as this protects the throat and hinders 
dental neuralgia. If shaved, the man looks like 
a eunuch. "Now I see boys and young men with 
beard and mustache shaved, and they call this 
Curzon fashion. Shaving has become the fashion 
both with Hindus and Mohammedans, though a 
bearded man among the latter is still shown more 
respect, and the mustache is clipped only as a 
religious rite." 

THE INDEX. 

The index for the volume covering the past six 
months will be published separately. A copy will be 
mailed to any. of our readers who will write for it. 



32 



XEirs ITEMS. 



IN' w York 
Medical Journal. 



News Items. 



Beer for Medicinal Purposes. — It is reported 
that a Wisconsin brewery has asked permission to 
make beer for medicinal purposes. The request has 
been refused for the present. 

Gift to Vienna Charities. — Richard Strauss, the 
composer, has ])laced a part of the proceeds of a 
successful Soutli American tour at the disposal of 
Viennese charities. The amount is estimated at 
tliree million kronen. Theatrical funds are to 
benefit, but most of the money is to be used to 
feed the children. 

State Clinics for Mental Disease. — Three new 
state hospital clinics for mental disease have been 
established recently, increasing- the total number to 
forty-one. One of these clinics is at Warsaw, 
Wyoming County, one at Glens Falls, and one in 
Geneva. The reestablished Peekskill clinic of the 
Hudson River State Hospital held its first session 
on November 5th. 

Medical Director of League of Red Cross So- 
cieties. — Colonel 1'. F. Longley, chief of the De- 
partment of Sanitation of the League of Red Cross 
Societies, has been appointed acting general medical 
director of the league following the departure of 
Dr. Hermann M. Biggs, health commissioner of 
New York State, who had temporarily assumed the 
duties of general medical director. 

Dr. Mosher Sues Nassau Electric Railroad. — ■ 
Dr. Burr Burton Mosher, of 11 Schermerhorn 
street, Brooklyn, has brought suit for $150,000 
damages against the Nassau Electric Railroad Com- 
pany for injuries he received on February 22d, 
last, when his motorcar was struck by a trolley at 
Atlantic and Flatbush avenues. It is alleged that 
the injuries compelled the doctor to abandon his 
activities, which had been numerous and varied, 
despite his sixty years. 

Urological Department Opened at New York 
Hospital. — The New York Hospital announces 
the opening of the Urological Department in ac- 
cordance with the terms of the will of the late 
James Buchanan Brady. Temporarily indoor 
quarters have been assigned to the department in the 
hospital at 8 West Sixteenth street. The out pa- 
tient clinic will be carried on in the out patient 
department of the hospital at the following hours : 
men: daily, 10 to 11 a. m. fexcept Wednesday) 
daily, 7 to 8 p. m. (except Tuesday). Women: 
Tuesday, 7 to 8 ]). m., Wednesday. 10 to 11 a. m. 

Insanity Damage Suit. — Dr. William B. Gib- 
son and Dr. Walter Lindsay are the defendants in 
a $1,000,000 damage suit brought by Ada M. and 
Phoebe K. Brush, formerly of Huntington, L. I., 
who were released from the State Hospital for the 
Insane at Kings Park, last March. The physicians 
signed the papers committing the women to the 
asylum, where they were confined ten years. The 
complaint alleges that the women were not insane 
when committed. Each of them is demanding 
$250,000 damages from each of the ])hysicians. 
The actions are brought in the Supreme Court of 
Westchester County. 



Harvey Society Lectures. — Dr. Alfred F. Hess, 
of the New York University and Bellevue Hospital 
Medical College, will deliver the fifth Harvey Society 
Lecture at the New York Academy of Medicine, 
Saturday evening, January 15th. His subject will 
be Newer Aspects of Some Nutritional Disorders. 

Rockefeller Foundation Grant for Cincinnati 
University. — The general education board of the 
Rnckfeller Foundation has ofifered to contribute 
$700,000 to the Medical College of the University 
of Cincinnati, on condition that the balance of 
$400,000 to complete the $2,000,000 endowment 
fund be subscribed. 

To Fight Antivaccination. — A public meeting 
will be held in Borough Kail, St. George, Staten 
Island, Friday evening, January 7th, to fight the 
recent movement against vaccination. Among the 
speakers will be Dr. Royal S. Copeland, health com- 
missioner, Dr. Lelsnd E. Cofer, health officer of 
the Port, Dr. Walter H. Park, director of health 
department laboratories, and Dr. S. Dana Hubbard, 
of the health department. Borough President Van 
Name will preside at the meeting and the Medical 
Society of the County of Richmond will attend in 
a body. 

A Dinner to Dr. Keen. — A dinner, followed by 
a reception, will be given to Dr. W. W. Keen of 
Philadelphia, by his friends and as.sociates, on his 
eighty-fourth liirthday, Thursday evening, Janu- 
ary 21st, at the Bellevue-Stratford Hotel. Many 
distinguished men, prominent not only in medicine 
but in military, diplomatic, educational, political 
and religious circles, will be present to participate 
in this tribute to Dr. Keen, the dean of American 
surgeons. A bronze bust of Dr. Keen, modelled 
for the occasion by a noted sculptor, will be pre- 
sented on behalf of those participating. 

Sheepskin Coats for Tuberculosis Patients. — 
The United States Public Health Service has pur- 
chased 2500 sheepskin lined coats for use in its 
tuberculosis hospitals. Clothed in these wind proof 
coats, which extend to the ankles, ex-service men 
are expected to enjoy the sunshiny winter days 
while taking the cure in their reclining chairs dur- 
ing the rest hours at Uncle Sam's various sanator- 
iums. A sufficient number of these coats have been 
sent to all the sanatoriums, both in the arid south- 
west and in the A.sheville .sector, as well as others 
throughout the country. Even those in southern 
California have not been neglected, as the days are 
sometimes chilly there. 

Suicides Follow Famine in China. — According 
to cable dispatches from Peking, starvation, suicide 
and murder are beginning to take their toll from 
China's famine sufl^erers. Efforts are beifig made 
to aid the unfortunates, but the workers are handi- 
capped by lack of funds and an insufficient number 
of relief workers, so they can .save but a small 
proportion of the millions who are doomed to die. 
The distress in China is well illustrated by the 
fact that at the French Hospital at Chengting-su, 
a handful of nuns are sheltering 2,056 aged 
famine victims in a space normally u.sed by fifty. 
The nuns are aided by the strongest of their charges 
in building shacks for the fast rising tide of famine 
sufferers. 



January I, 1921.] 



NEllS ITEMS. 



33 



Report of Jewish Hospital, Brooklyn. — The 
annua! report of the Jewish Hospital of Brooklyn 
for the fiscal year ending Octoher 31, 1920, shows 
an increase in the number of patients treated in the 
hospital over the previous year. In 1919, 5,928 
patients were treated and in this report 6,005 pa- 
tients are listed, with an average of 232 patients 
a day and 85,156 days of treatment. The ambu- 
lance' responded to 1,419 police calls. In the dispen- 
sary the number of patients dropped from 40.058 in 
1918, to 34,751 for this year, largely due to the 
discontinuance of the orthopedic clinic. 

Prohibition Gets Credit for Decrease in Insan- 
ity. — According- to Dr. Horatio M. Pollock, chief 
statistician of the State Hospital Commission, since 
the advent of prohibition there has been a consider- 
able decrease in the number of persons committed 
to State Hospitals for the Insane. Data gathered 
by Dr. Pollock show that a considerable percentage 
of the number of insanity cases in the state were 
caused by the excessive use of alcohol. In 1909, 
for instance, 10.8 per cent, of the persons com- 
mitted that year had become insane from alcoholism; 
this year the percentage of insanity cases caused by 
alcohol was only 1.9. 

Kings County Medical Society. — At the annual 
meeting of this society, lield Tuesday evening, 
December 21st, the following officers were elected: 

President, Dr. Arthur H. Bogart ; vice-president. 
Dr. Frank D. Jennings; secretary, Dr. Lewis H. 
Addoms ; associate secretary. Dr. Thomas M. Bren- 
-nan ; treasurer. Dr. Robert L. Moorhead ; associate 
treasurer. Dr. Alfred Bell ; directing librarian. Dr. 
William Browning; trustee, Dr. William Linder ; 
censors. Dr. John G. Williams, Dr. O. Paul Hump- 
stone, Dr. Robert Barber, Dr. H. T. Lang worthy. 
Dr. William H. Bayles. 

The following were elected delegates to the State 
convention: Dr. Russel S. Fowler, Dr. Charles E. 
Schofield, Dr. William F. Campbell, Dr. S. J. 
McNamara, Dr. William Linder, Dr. Edwin A. 
Griffin, Dr. Arthur H. Bogart, Dr. John J. Sheehv, 
T)r. Elias H. Bartley, Dr.' Walter D. Ludlum, Dr. 
Robert E. Coughlin, Dr. Calvin F. Barber, Dr. 
Roger Durham. 

Medical Unit for Eastern and Central Europe. 
- — Dr. Harry Plotz, medical adviser of the Jewish 
Joint Distribution Committee, will sail Wednesday 
for Europe to direct an overseas medical unit of 
tv.'enty American specialists, sanitarians, dentists 
■and pharmacists. The unit will serve for one year 
in the war stricken countries of Eastern and Central 
Europe, and will sail about January 15th. The unit 
will furnish medical supplies and surgical instru- 
ments to local doctors and hospitals, who now lack 
everything and as a result are helpless to combat the 
diseases sweeping the countries. It will also co- 
ojierate with the Governments in fighting epidemics, 
principally typhus ; conduct educational health cam- 
paigns, build baths and furnish soap and fuel for 
them, and organize boards of health in each com- 
munity so that the work of the unit will go on after 
it leaves Europe. Thi^ is the third American 
Jewish Relief unit sent to Eastern Europe within 
a year by the committee. An appropriation of 
'$2,000,000 for the unit's work has been made. 



Recurrence of Influenza Epidemic Uncertain. 
— Surgeon General Hugh S. Cumming, of the United 
States Public Health Service, says that while it 
cannot be definitely foretold whether there will 
be another epidemic of influenza this winter, it is 
his belief that even .should it become prevalent here 
and there it would not assume the epidemic pro- 
i)ortions of the past two years, nor would it rage 
in such severe form. As a result of careful analyses 
of the epidemiology of influenza it may be stated 
that an attack of influenza appears to confer a 
definite immunity to subsequent attacks, lasting for 
several years. 

Meetings of Local Medical Societies. — The fol- 
lowing medical societies will meet in New York 
during the coming week : 

AIoND.w, January jrd. — Clinical Society of the New- 
York Polyclinic Medical School and Hospital. 

Tuesday, Jmuary 4th. — New York Acadenw of Medi- 
cine (Section in Dermatology and Syphilis); Medical So- 
ciety of Harlem Hospital ; New York Neurological So- 
ciety ; Society of Alumni of Lebanon Hospital. 

Wednesday, January 5th. — New York .\ca'demy of Medi- 
cine (Section in Historical Medicine) ; Bronx Medical As- 
sociation : Harlem Medical Association ; Psychiatrical 
Society of New York (annual); Society of Alumni of 
Bellevue Hospital; Brooklyn Society for Neurology. 

Thursday, January 6th. — New York Academy of Medi- 
cine (stated meeting) ; Brooklyn Surgical Society (semi- 
annual meeting). 

Friday, January ^th. — New York .Academy of Medicine 
(Section in Surgery); New York Microscopical Society; 
Practitioners' Society of New York; .Alumni Association of 
Roosevelt Hospital ; Gynecological Society of Brooklyn. 

<$> 

Died. 

Backmax. — In Philadelphia, Pa., on Monday, December 
6th, Dr. Edward F. Backman, aged sixty years. 

BowLBY. — In Medical Lake, Wash., on Thursday, Decem- 
ber 9th, Dr. F. E. Bowlby, aged fifty three years. 

Douglas. — In Concord, N. H., on Friday, December 17th, 
Dr. Orlando B. Douglas, aged eighty-four years. 

Freeman. — In Philadelphia, Pa., on Monday, December 
20th. Dr. Walter J. Freeman, aged sixty years. 

HoLGATE. — In Los .Angeles, Cal., on Wednesday, Decem- 
ber 15th, Dr. Charles E. Holgate, aged forty-four years. 

■ Hellenstein. — In New York City, on Monday, Decem- 
ber 20th, Dr. Herman Hellenstein, aged fifty-eight years. 

Holgate. — In Los Angeles, Cal., on Tuesday, December 
14th, Dr. Charles E. Holgate, aged forty-six years. 

Kerr. — In Steubenville, Ohio, on Saturday, December 
11th, Dr. William B. Kerr, aged forty-three years. 

Labenberg. — In Richmond, Va., on Friday, December 
17th, Dr. Charles A. Labenberg, aged forty-four years. 

Marble. — In Worcester, Mass., on Thursday. December 
9th, Dr. John O. Marble, aged eighty-one years. 

Mills. — In Missoula, Mont., on Sunday, December Sth, 
Dr. William P. Mills, aged sixty-three years. 

Morehouse. — In West Orange. N. J., on Monday, De- 
cember 20th, Dr. James T. Morehouse, aged sixty-three 
years. 

Miner. — In Ware, Mass., on Sunday, December 19th, Dr. 
Worthington W. Miner, aged seventy -three years. 

Swift. — In New York City, on Monday, Decf^piber 20th, 
Dr. William J. Swift, aged sixty-eight years. 

Radebaugh. — In Pasadena, Cal., on Thursday, December 
16th, Dr. John M. Radebaugh, aged sixty-nine years. 

Williams. — Ii) Hartford, Conn., on Tuesday. December 
7th, Dr. May R. Williams, aged forty-si.x; years. 

Young. — In San Francisco, Cal., on Tuesdav. Nevemlx.'r 
16th, Dr. William S. S. Young. 



Book Reviews 



THE HEART AXD ITS DISORDERS. 

The Mechanism and Graphic Registration of the Heart Beat. 
By Thomas Lewis, M.D.' F.R.S., F.R.C.P., D.Sc, 
Honorary Consulting Physician, Ministry of Pensions ; 
Late Consulting Physician in Diseases of the Heart 
(Eastern Command) ; Physician of the Staff of the Royal 
Medical Research Committee, etc. Illustrated. New 
York: Paul B. Hoeber, 1920. Pp. xx-452. 

Heart Troubles. Their Prevention and Relief. By Louis 
Faugeres Bishop, M.A., M.D., Sc.D., F.A.C.P., Pro- 
fessor of the Heart and Circulatory Diseases, Fordham 
University ; School of Aledicine, New York City, Presi- 
dent of the Good Samaritan Dispensary ; Physician to 
the Lincoln Hospital, etc. Illustrated. New York and 
London : Funk & Wagnalls Company, 1920. Pp. xvi-422. 

The Diagnosis and Treatment of Heart Disease. Practical 
Points for Students and Practitioners. By E. M. Brock- 
bank, M.D. (Vict.), F.R.C.P. Hon. Physician, Royal 
Infirmary, Manchester, Lecturer in Clinical Medicine, 
Dean of Clinical Instruction, University of Manchester. 
Fourth Edition. Illustrated. New York : Paul B. Hoeber, 
Pp. viii-158. 

It may seem strange to group these three books 
and discuss them in one review, but the practitioner 
who has the interests of his patients in mind will 
be grateful for any knowledge that will aid him in 
his work. It may be said in reference to some 
cardiac disorders that the more we know the less 
we understand. In a study of cardiac conditions 
we cannot be limited to physical signs and graphic 
formulae. We have many other essential things 
to consider. What caused the lesion ? Could it 
have been prevented ? What can we do to help our 
patient? What can he do to help himself? How 
much real harm has been accomplished? How 
much work can the patient do ? These and a host of 
equally itnportant questions flock to us for answer. 
' * * * 

Some nine years ago Lewis brought out a mono- 
graph called The Mechanism of the Heart Beat. 
This w^as used for the foundation of the present 
book, which is a larger and a much more compre- 
hensive work. In it we find Lewis emphasizing his 
old but by no means unimportant warning, of how 
essential it is for the physician to use his senses in 
the diagnosis of the patient's condition. The patient 
and not the laboratory are to be the area of 
exploration in determining the extent of the injury. 
Wholesome warning and too frequently heeded. 
In his book he does not go into all the phases of 
cardiac disorders ; only certain ones are dealt with, 
but these with the thoroughness which marks the 
works of Lewis. 

Much new matter has been added to the original 
text in the first part of the book which deals with 
the anatomy and histology of the nodes and func- 
tional tissues. Here physiological principles are 
discussed and an explanation given for the normal 
pacemaker of the heart. We also have a presenta- 
tion of electrocardiographic deflections, and their 
changes in regard to their effect on either of the 
ventricles. This is then followed by various hypo- 
theses explaining the disorders of the mechanism 
of the heart as interpreted by the aid of the electro- 
cardiograph. Much experimental material has been 
used and examined in conjunction with the clinical 



records. The correlation of cardiac disorders foimd 
in patients and those of experimental origin is con- 
vincing. In this way a new light is given to the 
cardiac arrhythmias. Various heart blocks are 
analyzed ; those produced experimentally in animals 
and those encountered in the human. Evidence is 
submitted of the new rhjihm centres, both the atrio- 
ventricular rhythm and the much discussed idioven- 
tricular rhythm. 

Then step by step we have presented the various 
fibrillations, auricular and ventricular, with all their 
attendant variations, the heterogenic impulse, and 
the interrelation of extrasystole paroxysmal tachy- 
cardia and fil)rillation. and socalled sinoauricular 
heart block. A subject of widespread interest, one 
that demands the attention of workers in every field 
in medicine is cardiac syncope and unexpected death. 
As Lewis states the condition has for its primary 
cause a hidden or unrecognized defect of the 
nervous system, while in other cases the cardiovas- 
cular system is at fault and here the syncope is 
caused by a lack of arterial blood in the brain tissue. 
These cerebral anemias are then discussed at some 
length. Considering the difficulty in securing defi- 
nite evidence the situation is well w^orked out. 
Cases of clinical syncope are cited where the lesions 
were afterwards confirmed at autopsy. Standstill 
of the entire heart, of the ventricle, heart block and 
accelerated action are considered and carefully ex- 
plained. 

It may be worth while to quote from Lewis's 
introduction, for the following passages indicate 
what his general attitude is in regard to his own 
work : 

To advocate the general use of laboratory methods in- 
volving costly devices and time robbing technic is not my 
desire ; it is to emphasize the vital importance of methods 
of precision in progressive studies of disease while it is 
to be freely acknowledged that simpler methods are 
essential to the practice of medicine, it is clearly right to 
insist that in compiling reports contributory to scientific 
medicine precise methods are desirable. It is from this 
viewpoint that the example of electrocardiography is to 
be stressed. Inexact method of observation, as I believe, 
is one flaw in clinical pathologj' today. Prematurity of 
conclusion another and in part follows from the first 
Of the immediate value of graphic methods to 
practical medicine, it is my desire to speak but briefly. 
These records have placed the entire question of the human 
heart on a rational basis, so giving to the worker the con- 
fidence of knowledge ; they have influenced prognosis and 
have rendered it more e.xact ; they have potentially abolished 
the promiscuous administration of cardiac poisons, and 
have clearly shown the lines which therapy should follow. 
The new clinical observations have stimulated and directed 
a host of laboratory researches, anatomical, physiological, 
pathological and pharmacological of a valuable nature 
The book was written originally in the hope that 
it might stimulate the study of heart affections by precise 
methods. 

The author is not generally allowed to write his 
own review, even in part, but Lewis has so much 
to say that is important that in this case an excep- 
tion is made. There is no other worker in the field 
of cardiac patholog)^ to whom he can be compared. 
He stands alone in the portion of the field he has 
essayed to cover. His is the last word on the sub- 
ject today. 



Janunrv 1, 1921.] 



BOOK REVIEWS. 



35 



Bishop has tried to kill many birds with one 
stone. By his own confession his book is intended 
for "those who are sutfering from heart troubles 
or are interested in the subject. . . ." He 
wants to influence people to do those things for 
themselves that he lays out at the moment of the 
examination. He implies that the medical profes- 
sion has kept facts from the laity and that many 
more suffer from cardiac disorders than there are 
aware of their disease. This may be true. The 
belief that has been maintained among other work- 
ers in this field is that more persons have been 
treated for socalled heart disease than have it. 

in attempting to produce an appetizing morsel 
for the neurotic or the hypochondriac he immedi- 
ately makes his book semiscientific, which makes it 
of little value to the physician. It is like a child's 
version of the Arabian Nights Tales with all the 
spice removed so they may be safely read by the 
young folks. Now what is the situation as far as 
the layman is concerned? He who has no heart 
lesion has no need for the teachings and warnings 
in the book. He who has need for the teachings 
will not be able to handle the problems as outlined 
in this book. There are many problems to be con- 
sidered in addition to those set forth ; problems 
which require all the skill and training of a medical 
man and of a specialist, as a rule. 

Bishop, no doubt, is sincere when he presents his 
findings and he can see no reason why an ordinary 
reader cannot fully understand the things he has 
outlined in a fashion which to him seem quite clear. 
Yes, they seem simple to him because he has an 
extensive background of knowledge which he un- 
consciously assumes the reader also possesses. This 
is just what is meant by the adage that "A little 
knowledge is a dangerous thing." If he could sup- 
plement a medical course for the reader and a 
goodly amount of clinical experience then it might 
be well to give him the information — but even then, 
how niany physicians with all this knowledge would 
trust themselves to treat their own cardiac dis- 
orders ? 

This is not written in the spirit of criticism on 
account of any danger there might be in the num- 
ber of cardiac patients decreasing for the practi- 
tioner. Quite the contrary. Many readers of this 
Tiook will undoubtedly come to a physician to have 
their troubled minds set at rest and be told that 
their hearts are doing all that Nature intended them 
to do. The public should be educated along medical 
lines, but Bishop's method of approach is far from 
satisfactory in its results. 

^ ^ 

Convenient and complete is the verdict of ap- 
proval of this fourth edition of Brockbank's manual. 
It is simply what it purports to be, a pocket manual 
for clinical reference. In its modest way it com- 
pletely fulfils the requirements. It contains the 
essence of many more voluminous books and for 
the student and even the practitioner it aids in 
recalling the elaborate discussions found in more 
complete textbooks. In spite of the limitations of 
size physical signs are grouped in a convenient 
■fashion and none of the important ones omitted. 



THE POOR RICH. 

The Acjc of Innocence. By Edith Wharton. New York: 
D. Appleton and Company, 1920. Pp. 365. 

Tlie House of Lynch. By Leonard Merrick. With an 
Introduction by G. K. Chesterton. New York: E. P. 
Dutton & Company, 1920. Pp. 324. 

To group these two books in one review may be 
considered unfair to Edith Wharton, but since both 
have invaded the homes of the few — the rich — as 
settings for their stories, have flung open the doors 
of the new and the old aristocracies, the aristocra- 
cies founded on wealth, they must be content when 
they find themselves in the same first class compart- 
ments. Both of these authors, in former books, 
found their characters among the more lowly, 
if the more real, people of life. Let us now con- 
sider where they have reached a common ground in 
their invasion of the palaces of wealth ; let us see 
where they have diverged ; let us weigh their errors 
and their successes. 

In the case of Edith Wharton one is hardly aware 
that she has in the least strayed from her original 
surroundings. She enters the hushed drawing 
rooms in the town house, the doors of which are 
flung open for formal functions when the family 
name is at stake, or when there is danger of the 
breaking down of the formal barriers, and is quite 
at home. As she introduces us to one member of 
the family after another we have not the feeling of 
an invasion but we see the unfolding of characters, 
little souls in most instances, victims of environ- 
ment and a lack of initiative. They accept the 
orders and keep themselves away from their real 
wishes in accordance with the unwritten laws 
governing their class. Their characters are drawn 
with painstaking care. Her work is like delicate 
Chinese art, with great detail for the minute mark- 
ings and the same sophistication. She has shown 
the flimsy structure of high social life and how it 
shaped the course of the feeble characters caught 
in its meshes ; how the bolder spirits were censored ; 
how individualit}/ gave way to form; how charac- 
ters remained true to type and true to their early 
upbringing. She shows how the man in the story, 
we would call him hero but he rnight resent it, keeps 
away from the woman he really loves, marries a 
social inanimate doll, just because he has given his 
word. With great cleverness she reveals this 
apparently cold and sexless doll, the girl with the 
"almost boyish figure," as a subtle sphinx who, at 
the opportune moment, entangles him beyond all 
hope of recovery. She does this on various occa- 
sions without any sign of emotion, and it is only 
after her death that any inkling of it is revealed to 
her husband. 

In Edith Wharton's Ethan Tronic we see poverty 
keeping two lovers apart and sending them to a 
moral death mangled beyond recognition. They 
are kept as crippled prisoners for the rest of their 
lives under one roof within sight of each other. 
This is the story of two lovers and the third leg of 
the triangle a neurasthenic woman. Now she takes 
us to the rich and shows us how two lovers may 
be kept apart by wealth and spend a useless ex- 
istence, repressing their emotions, and making 
inarticulate cries in a most absurd sign language. 



36 



BOOK REVIEWS. 



[New York 
Medical Journal. 



In tlie case of Jltlian Proinc our sympathies are 
more readily enlisted, for the characters are helpless. 
The wife is dependent. . . . Here an adult 
semblance of a grown up point of view would save 
the day. .\ solution is not outside the realms 
of possibility. The situation is not hopeless, but 
the actors are too weak. In both instances the 
unloved women, the rich and the poor, made a 
desperate and successful effort to hold' the man — 
the male. In both instances they sensed the danger 
in an unconscious way, but they struck their blows 
with the unfailing precision of the hungry female 
spider who feasts on her unsuspecting mate. 

Many other points might be discussed in this 
work of art, for this it nmy be called with no 
apology. Wit and irony bring smiles and (luicken 
the reader's pulse. She has shown us humans in 
a most artificial environment and has done it so 
well that the most critical can find no fault. She 
has balanced her story with great precision, never 
once leading us into remote bypaths. She has con- 
densed her material, using no needless situations or 
words. The only feeble portion of the book is the 
epilogue, a glimpse of the newer generation with 
yet a glance at the past in retrospect where a more 
hopeful note is struck. Here we find a new code 
with new values based on achievement, not on 
family, on character not on wealth. Here she has 
attempted to quicken her cadence and bring things 
home by contrast. More convincing is the ending 
of the broken down family in Ethan Frame, in the 
tumble-down .shack with its crippled inmates. 

* * * 

Now a few words for Merrick. His is as the 
work of a clumsy mason. He too had a moral 
to teach, but in his crude way he robbed his 
story of any value it might have. The simple 
minded heroine, poverty stricken, with only two 
servants, and finally refusing her father's ill gotten 
millions ; the selfabnegation of hero and heroine ; 
the broken hearted, hard hearted irate parent ; much 
suffering, of the stage barnstorming variety ; lofty 
arguments ; silly chatter ; famous painting ; success ; 
. . . a solution of the millionaire problem; the 
refusal of the filthy millions. Perhaps we have an 
echo of the book in real life where a Boston youth 
has refused his father's millions. Who knows. 
Perhaps we will have a solution of the problem of 
the centralization of wealth. Perhaps the book will 
prove of great social worth. Perhaps. But it 
might be well to suggest to Merrick that he rewrite 
his story with more care and make his characters 
and the situations more in keeping with reality. 

THE GOLDEN BARQUE. 

The Golden Barque and The Weaver's Grave. By Seumas 
O'Kelly. New York and London : G. Putnam's Sons 
1920. Pp. 253. 

Mortimer Hehir, the weaver, was dead, and in 
search of his grave, bought and never used, came 
Meehaul Lynskey, the nailmaker, Cahir Bowes, the 
stone breaker, both his contemporaries, two young 
gravediggers, and his fourth wife, the other three 
being in the new graveyard. 

The two old men, proud of being chosen for 



the search, stand in Cloon na Morav, the Meadow 
of the Dead. No path, no plan or map or register 
to guide them, the gravediggers patiently follow 
their search, spades ready. Confessing they have 
forgotten, the widow goes to ask the whereabouts 
of tlie grave from a bedridden ancient, one Malachi 
Roohan, who in his moribund condition clings to 
his theory that everything and everybody is a dream. 
He .gives wrong directions as to the grave, but, 
suddenly, one of the old searchers remembers it. 
At the finish of the opening up, the handsomer of 
the gravediggers is smitten with love for the widow. 
She saw the figure of the man spring across the 
open black mouth of the weaver's grave. A faint 
sound escaped her, and then his breath was hot on 
her face, his mouth on her lips. Rather sudden, 
all this! 

The descriptions of old age, old graves, old 
memories, are capital. It cannot be called a story, 
though O'Kelly crowns his senilities with a warm 
living kiss. The book should be read in a sun- 
lighted, flower decked room, for the chill damps 
arising from Cloon na IMorav get into one's bones. 

********* 

It was a relief to board the Golden Barque with 
its genial boss, Martin Coughlan, proud of his canal 
boat, content with his little world, interested in but 
not disturbed by the mutual hatred of his two 
hands, Calcutta and Hike. Billy, the clown, and 
The Terror, a boy of eleven, his devoted admirer, 
make a clever chapter and brace us for another of 
O'Kelly's senile decayments — the Derelict, with his 
grizzled, long lined face, wisps of shaggy hair and 
head that hung level between the drooping shoul- 
ders. A mean, greedy crime has shrivelled him up, 
and makes him live near the canal in a most 
deserted, rheumaticky, squashy, briargrown lane. It 
is a relief when the boat passes his roofless house, 
and the story of how Martin Coughlan went on a 
committee and made a speech, or thought he did. 
cheers the reader up and makes him ready to wel- 
come O'Kelly's next volume. 

MARIE CLAIRE'S WORKSHOP. 

Marie Claire's Workshop. By Marguerite Audoux. Trans- 
lated by F. S. Flint. New York : Thomas Seltzer, 1920. 
Pp. 239. 

What of romance is to be had in the workroom 
of a Paris dressmaker? There is a smell of new 
stuflfs and of human beings, the noise of a machine, 
some half dozen girls, pretty, droll, sentimental, 
moody; a gentle patron who always pretends to be 
angry, and his clever, patient wife, who thinks she 
is making a good living when the workgirls are 
making one too. Nothing charms her more than 
when Ber^eounette, one lively worker, sings her 
droll little songs which cheer the whole room, and 
nothing alarms her more than the cold which is 
slowly killing little Sandrine. She sends her to her 
own doctor, who advises long rest and good food : 

"Sandrine laughed with all her heart. 'Rest? 
Where the deuce does he think I'm going to get 
that? I don't know any shop where they sell it.'" 
So, not knowing, tuberculosis claims the girl, who, 
though not married, has a lover and two children. 



Jaiuiarv 1. 1921.] 



BOOK REVIEWS. 



37 



a fact which liad excited no comment in the work- 
room, though Gabrielle, a new arrival, and preg- 
nant, is subjected to much chaff, even from the 
patron, concerning her appearance. It is awkward, 
too, for girls to die and to have babies when the 
season is at its height, and the description of over- 
time working is just one of those little descriptions 
in which the author excels : 

"Madame Linella must have her dress by ten on 
Sunday. 'Above all, make me sleeves which don't 
look like sleeves,' is the last demand from the 
imperious lady. 'The girls were all work worn,' 
said Marie Claire. 'I agreed to stay and help 
Madame Dalignac. The hours passed ; a church 
clock counted them one by one, without forgetting 
the quarters and the half hours, and the ' sounds 
entered the open window as if their mission were 
to remind us that we had not a minute to lose. The 
twelve strokes of midnight echoed for so long that 
Mme. Dalignac went and shut the window, but the 
hours which followed did not tire. Now and then 
she was overcome by sleep. She let go of her 
needle suddenly and her head fell forward. . . . 
The church clock suddenly counted three. She put 
down her work and got up painfully to go and 
make tea. ... I understood the day was breaking. 
Then I let my body huddle into rest and yielded 
unto the immense desire for a few minutes' sleep. 
. . . "Sleeves that don't look like sleeves." Madam 
worked an hour on them. . . . She gave way sud- 
denly, and fell on her knees. I jumped up to help, 
but saw she was in a deep sleep. I slipped a roll 
of lining beneath her head, and, fearing I should 
go to sleep like her, I passed a damp cloth over my 
face. "Sleeves that don't look like sleeves." I 
looked at them for a long time, then undid them. 
. . . Six o'clock struck. The sun, passing over the 
new house opposite, sought to frame itself in a 
window pane, and blinded me. My eyelids closed, 
and for a moment sleep crushed me. Then a sort of 
numbness seized me. It seemed to me that a great 
hole was forming in my chest, and there was nothing 
left in me but the fixed idea that the dress must 
be delivered at all costs before ten o'clock.' " 

The scene in detail, the two feverish women try- 
ing to keep awake, the smell of the dying lamp 
mingling with the stuffiness of the room, are fine 
portrayals of sordidness, of utter weariness. It is 
the same in her description of the Luxembourg 
on a winter morning. She even finds something 
interesting in the postures of the iron chairs put 
aside till the spring, and sprawling in grotesque 
attitudes. 

When Marie Claire takes the old sewing woman, 
Herminie, down to Burgundy to give the old soul 
a look at her native village, we share the excitement 
and strain to catch first glimpse of the so white, 
dusty roads, the vineyards, the fruit trees, but time 
has changed all things remorselessly, save the sun- 
set and the roads. You get right into the hot, 
hushed air of a summer evening in the vine districts, 
you see the full moon rising and drawing from the 
earth light mists, and hear the hundred voices of 
insects among the dusty roadside weeds, and the 
frogs in the half dried ponds. The end of a long 
day of trying to restore old scenes has wearied old 



Herminie sorely. "Seated on the cruml)ling stones, 
her hands hanging limply, and her head flung back, 
she was uttering a long and monotonous cry. 'Let 
us be off!' she cried, and dragged me toward the 
station." 

The small tragedies of seamstress life are drawn 
with a blunt pencil ; there is no time to stay work 
when Gabrielle is run over and her unborn infant 
killed, though all agree the fall had solved a diffi- 
cult question. The engagement of Marie Claire 
to Clement, the patron's nei)hew, lightens the gloom 
which lowers when a neglected illness takes the 
patron also. The author has a rare fashion ot 
making things animate and inanimate give a replica 
or express the idea of that which is happening in 
the human lives. The patron and his good wife are 
facing evil times : the shadow of death and debt is 
falling. One day a little mouse appears; the cat 
is fetched. The capture, the torturing play, the 
defiance of the tiny creature with its bleeding jaws, 
are an echo of the patron and his wife defying the 
shadows. The cat and mouse struggle accentuate, 
create a sympathetic realization of the human crisis. 

It is an enticing little story, and the reader needed 
no bookmark, for the end was reached before the 
volume was put down. 

THE AMERICAN REVIEW OF 
TUBERCULOSIS. 

In the issue of the New York Medical Journal 
of December 4th, the reviewer had occasion to speak 
of the Zcitschrift fiir Tubcrkulosc, now edited by 
Professors Kirchner, Kraus, V. Leube, Orth, Pen- 
zoldt, Kuttner, and Lydia Rabinowitsch. This 
was in reference to the first number sent for review 
since the declaration of the war. The Zeitschrift 
had its beginning in 1900 under the editorship of 
C. Gerhardt, Frankel, and E. von Leyden. All 
three of these men have since gone to the great 
beyond. In the year 1916, American tuberculosis 
workers felt the need of a scientific publication 
similar to the German Zeitschrift which then ar- 
rived very irregularly in this country owing to war 
conditions. Today it is the reviewer's privilege to 
speak of this home product, which is in every way 
equal, if not superior, to this veteran German jour- 
nal on tuberculosis science. 

The American Review of Tuberculosis was 
started in 1916 with Edward R. Baldwin, of Sara- 
nac Lake, as editor in chief, and Allen K. Krause, 
of Johns Hopkins Hospital, Baltimore, as editor. 
Lawrason Brown, H. R. M. Landis, Paul A. Lewis, 
M. J. Rosenau, Henry Sewall, and Borden S. 
Veeder have since been added to the editorial staff ; 
George Mannheimer is abstract editor. Before us 
is the November number of 1920. The mere men- 
tion of some of the contributions to this number 
will give an idea of the character of the publication : 
First Infection with Tuberculosis by Way of the 
Lungs, by Eugene L. Opie and Hans Andersen ; 
A Rontgenological Study of Influenza, with Re- 
covery, in an Advanced Case of Pulmonary Tuber- 
culosis, by Louisa T. Black and Mary Moore ; 
Masked Juvenile Tuberculosis, by J. V. Cooke and 
T. C. Hempelmann ; A Comparison of Gross Tuber- 
culous Lesions in Whites and Negroes, As Based 



38 



BOOK REVIEWS. 



[New York 
Medical Journal. 



on 150 Autopsies, by J. B. Rogers; Experimental 
Lesions of the Lungs Produced by the Inhalation 
of Fluids from the Nose and Throat, by W. V. 
Mullin and C. T. Ryder; Environmental Factors 
in Tuberculosis, by Allen K. Krause. It is obvi- 
ously impossible to review all of these articles in 
the limited space which can be given to it in an 
important medical journal, and every one of them 
has distinct scientific merit. The reviewer has been 
a sub-scriber to this periodical from its very begin- 
ning, and may conscientiously state that it has 
constantly grown in excellence. 

To quote again from the contents of two more of 
this year's issues will give a further idea of the scope 
of the Review. In the February number, S. Adol- 
phus Knopf pays a tribute to the great William 
Osier, an honorary vice-president of the National 
Tuberculosis Association, and gives a list of the 
great physician's contributions relating to tuber- 
culosis. There is a highly interesting article on 
Observations on the Artificial Tuberculous Infec- 
tion of Guinea Pigs through the Respiratory Route, 
by J. B. Rogers; also on Pulmonary Syphilis, by 
Elmer H. Funk. We may also mention An Un- 
usual Case of Pulmonary Tuberculosis — Terminat- 
ing in Spontaneous Hemopneumothorax Following 
Artificial Pneumothorax, by Fred H. Heise and 
Allen K. Krause. 

In the September number Horace J. Howe and 
William E. Lawson write on The Influence of 
Smallpox and Vaccination on Pulmonary Tuber- 
culosis ; James Alexander Miller gives us Some 
Problems in the Dififerential Diagnosis of Pul- 
monary Tuberculosis ; Francis B. Trudeau presents 
The Importance of Physical Signs in the Prognosis 
of Pulmonary Tuberculosis; B. Suyenaga, An In- 
vestigation of the Acid Fastness of Tubercle 
Bacilli, II ; Selig Simon, Artificial Heliotherapy in 
Pulmonary Tuberculosis ; Louis C. Boisliniere, 
Influenza as a Factor in the Activation of Latent 
l\iberculosis ; Ethan E. Gray, The Surgeon and 
the Consumptive ; S. W. Schaefifer, Silence in the 
Treatment of Pulmonary Tuberculosis. 

Every number contains abstracts and articles on 
tuberculosis and allied subjects from all the leading 
medical journals of the world; many articles 
are handsomely illustrated by original drawings 
or radiographic pictures. The Reviezv is issued 
monthly, appearing about the twentieth of the 
month. A volume includes twelve numbers and 
begins with the March number. The subscription 
price to members of the National Tuberculosis 
Association is $2 a volume, with twenty-five cents 
additional for Canada and fifty cents additional for 
other foreign postage ; and $5 a volume to non- 
members, foreign postage included. Subscriptions 
may be sent • to Williams & Wilkins Company, 
Mount Royal and Guilford Avenues, Baltimore, 
]Md., or to the National Tuberculosis Association, 
381 Fourth Avenue, New York City. 

The American Rei'iew of Tuberculosis is not only 
indispensable to the specialist and student in tuber- 
culosis, but equally so to the general practitioner 
who must keep informed on these subjects if he 
desires to do his duty to his tuberculous patients 
and to himself. 



New Publications Received. 



[We publish full lists of books received, but we acknowl- 
edge no obligation to review them all. Nevertheless, so 
far as space permits, we review those in which we think 
our readers are likely to be interested.] 



ONE HUNDRED PER CENT. The Story of a Patriot. By 
Upton Sinclair. Pasadena : Published by the Author, 
1920. Pp. 329. 

THREE PLAYS. By Brieux, Member of the French 
.\cademy. With Preface by Bernard Shaw. New York : 
Brentano's, 1920. Pp. liv- 333. 

contemporary RUSSIAN NOVELISTS. Translated from the 
French of Serge Pershy by Frederick Eisemann. Boston : 
John W. Luce and Company, 1913. Pp. 317. 

philosophic nights in PARIS. By Remy de Gourmont. 
Being Selections from Promenades Philosophique. Trans- 
lated by Isaac Goldberg. Boston : John W. Luce and Com- 
pany, 1920. Pp. 193. 

old at forty or young at sixty. Simplifying the Science 
of Growing Old. By Robert S. Carroll, M.D., Medical 
Director, Highland Hospital, Asheville, North Carolina. 
New York: The Macmillan Company, 1920. Pp. 147. 

psychopathology. By Edward J. Kempf, M.D., Clinical 
Psychiatrist to St. Elizabeth's Hospital (Formerly Govern- 
ment Hospital for the Insane), Washington, D. C. ; Author 
of The Autonomic Functions and the Personality. Eighty- 
seven Illustrations. St. Louis : C. V. Mosbv Compan^•, 
1920. Pp. xxiii-762. 

types of mental defectives. By M.\rtin W. Barr, 
M.D., Chief Physician, Pennsylvania Training School for 
Feebleminded Children, Elwyn, Pa., and E. F. Maloney, 
A.B., Professor of English, Girard College. With 31 
Plates Containing 188 Illustrations. Philadelphia: P. Blakis- 
ton's Son & Co., 1920. Pp. ix-175. 

the community he.\lth problem. By Athel Campbell 
Burnham, M.D., Health Service, Atlantic Division, 
American Red Cross ; Attending Surgeon, Volunteer Hospi- 
tal, New York City; Lieutenant Colonel, Medical Reserve 
Corps, U. S. Armv etc. New York : The Macmillan Com- 
pany, 1920. Pp. 149. 

textbook of nervous diseases. For the Use of Students 
and Practitioners of Medicine. By Ch.^rles L. Dana. 

A. M., M.D., LL.D., Professor of Nervous Diseases in 
Cornell University Medical College ; Consulting Physician 
to Bellevue Hospital ; Neurologist to the Aiontefiiore Hos- 
pital, etc. Ninth Edition. With 262 Illustrations, Including 
4 Plates in Black and Colors. New York : William Wood 
and Company, 1920. Pp. x-655. 

THE radiography OF THE CHEST. Vol. I. PULMONARY 

tuberculosis. W'ith Nine Line Diagrams and Ninety-nine 
Radiograms. By Walker Overend, M.A., M.D. (Oxon). 

B. Sc. (Lond.) Hon. Radiologist and Physician to the 
Electrotherapeutic Department, East Sussex Hospital 
(Hastings) ; Radiologist to the City of London Hospital 
for Diseases of the Chest (during the war) etc. St. Louis: 

C. V. Mosby Company, 1920. Pp. 119. 

hy^giene and communicable diseases, a Handbook for 
Sanitarians, Medical Officers of the Army and Navy and 
General Practitioners. By Francis M. Munson, M.D., 
Lieutenant, Medical Corps, U. S. N., Retired ; Lecturer on 
Hygiene and Instructor in Military Surgery, School of 
Medicine, Georgetown University ; Formerly Instructor in 
Medical Zoology, Georgetown College, etc. Illustrated. 
New York: Paul B. Hoeber, 1920. Pp. xiv-793. 

THE course of OPERATIVE SURGERY. A Handbook for 
Practitioners and Students. By Prof. Dr. Victor 
Schmieden, Lately Assistant in the Royal Surgical Clinic 
in the University of Berlin; Professor of Surgery in the 
University of Halle, and Arthur Turnbull, M. B., Ch.B. 
(Glasg.) Lately Demonstrator of Anatomy in the Uni- 
versity of Glasgow. With a Foreword by Prof. Dr. A. 
Bier. Second Enlarged English Edition. New York: 
William Wood and Company, 1920. Pp. xx-349. 



Practical Therapeutics and Preventive Medicine 

A Compendium of Treatment and Prophylaxis, Original and Adapted 



Cholecystgastrostomy. — • Charles S. White 
{Surgery, Gynecology and Obstetrics, November, 
1920) states tliat the operation of cholecystgastros- 
tomy has a definite place in surgery and the follow- 
ing may be concluded in regard to the operation : 
1. The operation is indicated in an irremediable 
obstruction of the common duct or division of the 
duct which cannot be successfully sutured. 2. For 
long continued drainage in infective biliary cirrhosis 
it is superior to cholecystostomy in that nutrition is 
maintained. 3. It is not a difficult operation, being 
easier and safer to perform than an anastomosis 
between the gallbladder and the small or large 
intestine. 4. There is no danger of an ascending 
infection. 5. The presence of bile in the stomach, 
while unphysiological in a degree, is consistent with 
good digestion, and offers no argument against the 
operation. 6. The suture method of anastomosis is 
the only one to be employed. 

Perforation of the Cecum. — Edward H. Risley 
(Boston Medical and Surgical Journal, June 10, 
1920) reports a case in which the special points of 
interest were: 1. The finding of a recently given 
turpentine enema free in the abdominal cavity, its 
entrance being through a perforation in the cecum 
where a completely gangrenous appendix had been 
sloughed off. The question may, of course, be 
raised as to whether or not the turpentine enema 
did not actually produce the perforation, or at least 
hasten it by several hours. 2. Recovery from 
general peritonitis and three secondary hemorrhages 
occurring as late as the eighth, seventeenth, and 
twenty-first days after operation. 3. Later finding 
of "virgin" peritoneum with no adhesions' even 
after so severe a peritonitis. 4. Unusually late, 
overwhelming, but short toxic erythema with sud- 
den onset and equally sudden recovery. 

The Treatment of Chronic Gastritis. — George 
M. Niles (Charlotte Medical Journal, August, 
1920) divides the treatment into prophylactic, 
hygienic, local, dietetic, medicinal, and mineral 
water. Under the head of prophylactic treatment, 
all contributing or aggravating causes should be 
corrected. Deliberate eating, adequate mastication, 
and thorough insalivation should be insisted upon, 
also the treatment of pyorrhea, if it is present. It 
is well to rest both before and after meals. Locally, 
excessive mucus should be removed and the gastric 
mucosa soothed. Hot water and alkaline medicines 
help. Lavage is indicated in the presence of exces- 
sive mucus, which envelops the food and prevents 
its saturation by the gastric juices. Lavage should 
not be performed oftener than once a day, and the 
stomach should be free of food. It is well to use 
plain water at first ; later, potassium permanganate, 
one grain to the pint ; sodium bicarbonate, sodium 
chloride, silver nitrate (five grains to the pint; cal- 
cined magnesia, or boric acid. Where marked atony 
is present electricity should be employed. A diet 
rich in carbohydrate with a minimum of proteid is 



desirable. For hyperacidity, alkalies should be 
used ; in subacidity or achylia, dilute hydrochloric 
acid, six to ten drops, may be given after meals. 
This can be administered either alone or in com- 
bination with pepsin or nux vomica. Before meals 
quassia, condurango or cinchona may be given. 
Mineral waters are used to stimulate secretion. 

Multiple Resections of the Small Intestine. — 
Ernest L. Hunt (Boston Medical and Surgical 
Journal, September 2, 1920) says that in cases of 
severe traumatism to the intestine multiple resec- 
tions are possible and to be utilized where a single 
resection would deprive the patient of an undue 
amount of bowel. In such cases, where the para- 
lytic ileus has begun or its supervention is to be 
clearly anticipated, primary enterostomy ])roximal 
to the traumatized area is theoretically indicated. 
In cases of postoperative ileus enterostomy should 
not be too long deferred. Its proved value entitles 
the patient to its benefits without waste of time 
on less efficient measures. 

Interperitoneal Adhesions. — R. J. Behan 
(American Journal of the Medical Sciences. Sep- 
tember, 1920) discusses the results of his experi- 
mental investigations concerning interperitoneal ad- 
hesions, and advocates the application of a five per 
cent, mixture of boric acid with lanolin to the peri- 
toneal surfaces, which he has found to give much 
relief from pain and to tend to prevent adhesions, 
although it does not do the latter with certainty. 
The lanolin must be as pure as possible. Most of 
that on the market is contaminated in various ways. 
It should also be sterilized three times on three 
different days, each time for half an hour at a 
temperature of over 212°. Before being used it 
should be heated so that it is absolutely fluid, and 
should be applied very hot to the peritoneal surface. 
The bowel should be dry before its application. 
It does not act in the presence of inflammation. 

Treatment of Cancer of the Rectum. — Charles 
J. Drueck (American Journal of Surgery, August, 
1920) in giving the treatment of cancer of the 
rectum formulates the following in regard to the 
technic of the operation which must be strictly 
adhered to if satisfactory results are to be obtained : 
1. That an abdominal anus is necessary. 2. That 
the whole pelvic colon, with the exception of the 
part from which the colostomy is made, must be 
removed because its blood supply is contained in 
the zone of upward spread. 3. That the whole of 
the pelvic mesocolon below the point where it crosses 
the common iliac artery, together with a strip of 
peritoneum at least an inch wide on either side of 
it, must be cleared away. 4. That the group of 
lymph nodes situated over the bifurcation of the 
common iliac artery are in all instances to be re- 
moved. 5. That the peritoneal portion of the 
operation should be carried out as widely as possible 
so that the lateral and downward zones of spread 
may be effectively extirpated. 



40 



PRACTICAL THERAPEUTICS AND PREVENTIVE MEDICINE. 



[New York 
Medical JournalI 



The Mental Factor in the Chronic Intestinal 
Invalid. — John Bryant (Boston Medical and Sur- 
gical Journal, February 26, 1920) reports two cases 
which illustrate two distinct types of mental com- 
motion which are often encountered in the treat- 
ment of the chronic intestinal invalid. In one the 
mental commotion was due to a summation of 
general causes ; in the other it was due to two spe- 
cific factors ; in both the relief of the mental com- 
motion proved to be a very important factor in 
the recovery of the patient. 

Early Radioscopic Signs of Pyloric Stenosis. — 
De Keating-Hart {Prcsse medicalc, April 10, 1920) 
describes two signs which have already enabled him 
in a number of instances to detect pyloric stenosis 
before clinical or x ray findings had revealed its 
presence. The first sign is a particular change of 
shape in the gastric shadow whereby the latter 
assumes the appearance of a German pipe. The 
other sign is an interrupted, rhythmical displace- 
ment of the upper surface of the fluid contained in 
the stomach. This displacement is synchronous 
with the respiratory movements but is of greater 
amplitude, indicating a pronounced effort on tht 
part of the organ to empty itself. The first of these 
manifestations is only a probable sign of pyloric 
stenosis, but the second is a certain sign of it. 

The Tongue : Its Indication for Treatment of 
Disease. — M; W. Thewlis (Medical Reviezv of 
Reviews, June, 1920) says that a study of the 
tongue will give many valuable suggestions for 
treatment of disease ; it is often disregarded, espe- 
cially by young practitioners. A red, clean tongue 
is an indication for an acid mixture; red tongue 
with prominent papilliE is an indication for the use 
of small doses of arsenic. Acids will relieve an 
acid stomach and alkalies will relieve an alkaline 
condition. Coated tongue is an indication, for 
mercury and a saHne laxative; if stools are light in 
color, mercury is indicated ; if dark, podophyllin is 
needed. A moist tongue which becomes dry under 
alcoholic stimulation denotes that the latter is doing 
harm. The tongue is often dry in the aged. 

Acute Infectious Enteritis with a Polyneuritic 
Syndrome. — Frederic J. Farnell and Arthur H 
Harrington (American Journal of the Medical 
Sc ienccs, July, 1920) r-^port fifteen cases of this 
nature. To sum up this report, it would appear 
that there was introduced into the body an exogen- 
ous toxin (staphylococcus infection) ; that it was 
introduced into the gastrointestinal system and 
there produced an acute infective gastroenteritis ; 
that there was a transmission of the infective agent 
from the intestinal tract to the general circulation, 
producing a septicemia, staphylococcus in type ; 
that for reasons not yet explained this particular 
infection had a selective action upon the peripheral 
nervous system and caused the symptom-complex 
known as peripheral polyneuritis ; clinicopathologic- 
ally the milk, throat cultures, tlood, fecal examina- 
tions, and urinary tests for bacteria showed in gen- 
eral the staphylococcus; pathologically there was 
observed an acute hemorrhagic gastroenteritis, mul- 
tiple focal necroses of infectious origin in the liver, 
and acute hemorrhagic neuritis with hemorrhages 
between the nerve bundles. . 



Botulism from Canned Ripe Olives. — Herbert 

W. Emerson and George W. Collins (Journal of 
Laboratory and Clinical Medicine, June, 1920) 
state that five small outbreaks of botulism have 
occurred in the last six months, caused by eating 
ripe olives packed in glass containers. Four of 
the outbreaks were due to Bacillus botulinus of the 
Boise type, or Type A. Antitoxin for one type is 
specific for that type alone. As a preventive meas- 
ure against the occurrence of further outbreaks of 
botulism, the authors recommend the advisability 
of government supervision over the plants, which 
supervision should also include the packing and 
canning plants. 

The Saliva in Diabetics. — F. Rathery and L. 

Binet (^Prcsse medicalc, May 1, 1920) state that the 
saliva of diabetics presents certain special features,, 
being scanty, often viscid, rather frequently acid in 
reaction, and in some instances containing notable 
amounts of glucose. They were able to show ex- 
perimentally that in anirhals in which the blood 
sugar has been increased either by intravenous in- 
jection of glucose or by complete pancreatectomy 
elimination of sugar through the salivary glands 
takes place. There occurs clinically a condition that 
may be termed glycosialorrhea. This condition may 
accompany glycosuria, alternate with it, or occur 
independently without the appearance of any sugar 
in the urine. 

Experiments on the Utilization of the Calcium 
of Carrots by Man. — Mary Swartz Rose (Journal 
of Biological Chemistry, March, 1920) carried out 
feeding experiments on four healthy young women 
to determine the utilization of the calcium of car- 
rots. In all cases the calcium intake was near the 
estimated minimum for equilibrium. Three of the 
subjects showed a positive calcium balance, and in 
the fourth case the loss was. small. When the 
carrots supplied about fifty-five per cent, of the .cal- 
cium one of the subjects had about the same reten- 
tion as when she was on a diet in which seventy per 
cent, of the calcium was derived from milk. Thus 
it is apparently possible to meet the requirement of 
the adult human for calcium largely, if not wholly, 
from carrots. 

Antiscorbutic Properties of Raw Beef. — R. Ad- 
ams Butcher, Edith M. Pierson. and Alice Blester 
(Journal of Biological Chemistry, 1920) fed guinea- 
pigs on a diet of oats, water, and an amount of milk 
sufficient to improve the diet but insufficient to 
prevent scurvy (twenty-five c. c. of autoclaved 
milk, or twenty c. c. of pasteurized milk). Scurvy 
developed and the animals died. To. this diet were 
added water extracts of raw lean beef, representing 
five, ten, fifteen, and twenty gm. of raw beef. How- 
ever, this had no effect on the time of onset of 
scurvy or in the length of life of the experimental 
animals. On the addition of orange juice to the 
basal diet scurvy was prevented, both in the presence 
or absence of meat extract. The conclusion is 
drawn that the excellent condition of the animals 
on the orange juice and beef extract diet shows 
conclusively that the poor condition of the animals 
on the beef extract diet was due to the absence of 
the antiscorbutic vitamine rather than to any dele- 
terious properties of the beef. 



January I, 1921.] PRACTICAL THERAPEUTICS AND PREVENTIVE MEDICINE. 



41 



Observations upon Various Types of Diabetics 
under the Present Method of Treatment. — F. 

Gorhani Brigham (Boston Medical and Surgical 
Journal, August 5, 1920) presents the following con- 
clusions based on a study of a large number of 
diabetics over a period of ten years: 1. That by all 
the modern methods of low calory diet the diabetic 
patients do better than by former methods. 2. That 
without careful blood estimations diabetics cannot 
be satisfactorily treated and good results obtained. 
3. That the complications of diabetes will develop 
even though the urine contains no stigar if the blood 
figures remain high. 4. That the prevention of 
obesity will reduce the number of diabetics tremen- 
dously. 5. That the stud/ of other functions, 
such as the kidney function, and the removal of all 
possible foci of infection, are essential to having the 
diabetic patient do well. 6. That rRutine twenty- 
four hour urines must be more frequently done, or 
routinely done, to be able to recognize diabetes as 
well as other kidney conditions early, and allow 
earlier treatment. 7. That the disease diabetes illus- 
trates the importance of laboratories where simple 
routine analyses can be done at a reasonable figure. 

The Islands of Langerhans in Diabetes. — 

Moses Baron (Surc/crv, Gynecology, and Obstet- 
rics, November, 1920) concludes that: 

1. Pancreatic lithiasis is a rare disease, which 
occurs mostly in males during the fourth decade. 

2. The obstruction of the pancreatic duct leads 
to an advanced atrophy of the pancreas accompanied 
more or less by fibrosis. The islets may remain 
intact even when the acini disappear completely. 

3. The islets as epithelial structtires which are 
entirely independent of the acini and have no rela- 
tion to or communication with the dticts. 

4. Changes in the islets — such as degeneration, 
necrosis and fibrosis — generally occur late in the 
disease, probably as a result of a superimposed 
secondary infection, consequent to a prolonged 
stasis in the ducts. 

5. In complete accord with the results obtained 
experimentally in animals, occlusion of the ducts by 
calculi in man does not result in diabetes mellitus 
unless there be actual injury to the islets. 

6. Cases of pancreatic lithiasis presenting symp- 
toms of hyperglycemia and glycosuria reveal definite 
lesions of the islets at atitopsy. 

7. The sttidy made bears out the conclusions that 
the islets secrete a hormone directly into the lymph 
or blood streams (internal secretion), which has a 
controlling power over carbohydrate metabolism. 

8. Attempts at regeneration of injured pancreatic 
tissue manifest themselves in a definite hyperplasia 
of the ducts. 

9. The principal clinical findings in cases of 
pancreatic lithiasis are coliclike epigastric pains 
often associated with temporary glycosuria, steator- 
rhea, alimentary glycosuria, incomplete digestion of 
meat fibres as revealed by the persistence of the 
nuclei in muscle fibres in the feces, and, occasionally, 
the presence of whitish or grayish pancreatic stones 
in the feces ; the late stages are often accompanied 
by diabetes mellitus. 

10. Operations on the pancreatic duct are often 
successful. The danger of fat necrosis as a result 



of the escai)e of fluid appears to be negligible. 

11. The histopathology of the islets in diabetes 
falls into three main types, wJiich are, in the order 
of their importance, as follows : fibrosis, hyaline 
degeneration, and arteriosclerotic changes. The 
pathogenesis of these lesions may not be very dis- 
similar to that of nephritis when taken in the broad 
sense. The differences in the intensity of the 
pathological changes in the kidney as compared with 
those in the pancreas may be explained by the 
marked dififerences in the characters of the two 
organs. In the kidneys, any glomerulitis or other 
changes in the glomeruli are followed or accom- 
panied by alterations in the tubules ; no such changes 
affect the tubules or acini in the pancreas, since the' 
islets are entirely distinct from the latter structures. 

Blood and Urine in Pancreatic Disease. — -Cam- 
midge and others (Lancet, August 21, 1920) estab- 
lish a relationship between the amount of dextrin 
in urine and blood (which they name the difference 
valtie), and the state of the pancreas. The authors 
describe a method for measuring this difference 
value. They find, 1, that the proportion of dextrin 
in the blood varies directly with that in the urine ; 2, 
that the proportion of amylolytic ferment in the 
blood and urine varies inversely as the difference 
value and directly as the percentage of sugar 
present, and, 3, that both are dependent on the 
sugar present. Control experiments on depancre- 
ated animals indicate that an increase in the dif- 
ference value of the blood is a prediabetic condition. 

1. When the gland is partly or wholly removed 
or functionally impaired, the sugar content and 
the difference value of the blood and urine rise. 

2. The substance on which the difference value 
depends is derived from the glycogen of the liver. 

3. An amylolytic ferment which acts on the glyco- 
gen is released from the liver into the blood or urine. 

4. In the normal state the pancreatic secretions and 
the ferment of the liver maintain a balance which is 
disturbed in disease, resulting in abnormal conditions. 

5. When pancreatic activity is decreased the dex- 
trin content first and then the sugar content is 
increased and a prediabetic condition occurs, fol- 
lowed by hyperglycemia and glycosuria. 

A Case of Paget's Disease Following a Trauma. 
— Dr. Stefano Gatti (Arcliivio generate di ncuro- 
logia e psichiatria, March, 1920) describes in full the 
history and clinical symptoms of a case of Paget's 
disease in which radiology confirms his diagnosis and 
helps to exclude other diagnostic possibilities. It 
also shows very clearly the structural peculiarities 
of the osteitic process, in this case downward toward 
the knee joint and upward as far as the sacroiliac 
articulation. The patient's ascendents had shown 
in their history tuberculosis and scrofula on the 
father's side, general paresis in the mother, with 
cardiovascular difficulties on both sides. The patient 
showed no syphilitic signs. It is believed that the 
trauma he sustained, a fall upon the ice, acted 
through a lesion of the sympathetic upon a constitu- 
tion predisposed to trophic alterations of a pluri- 
glandular nature. To the general hormonic dis- 
equilibrium the trauma added dynamic vasomotor 
factors causing a special perversion of the dystrophy 
manifested especially in the osteitis. 



Proceedings of National and Local Societies 



AMERICAN PEDIATRIC SOCIETY. 

Thirtv-second Annual Meeting, Held in Highland 
'Park, III., May 31, June 1 and 2, 1920. 

The President, Dr. Thomas S. Southworth, of New York, 
in the Chair. 

( Continued from page 1052, Vol. cxii.) 

Paralysis of the Respiratory Muscles. — Dr. 

W. McKiM Marriott, of St. Louis, said the chief 
interest in this case was in the treatment applied. 
The patient was a girl ten years of age who had 
sut¥ered from a severe attack of diphtheria six 
weeks previously. Paralysis developed of the 
palate, ocular muscles, legs, back and neck muscles, 
and partial paralysis of the arms. Ultimately the 
diaphragm became involved, so that it failed to 
move at all during inspiration. The thoracic 
respirations were at first very active, later the inter- 
costal muscles began to lose their power and the 
child became cyanotic and semicomatose. The child 
was obviously dying from suffocation, and it was 
thought that if the respirations could be maintained 
for a sufBcient period of time to allow for restora- 
tion of function of the respiratory muscles that 
recovery would be possible. Artificial respiration 
was given by means of the Erlanger-Gessel air cur- 
rent , interrupter connected with a nitrous oxide 
mask. The child failed to cooperate at first, but 
later it was possible to get her to open the glottis 
at the right time so that air could be forced into 
the lungs at the regular rate. The effect was 
immediate. The cyanosis was relieved and after a 
period of about ten minutes of artificial respiration 
the child fell asleep and the mask was removed. 
Cyanosis slowly developed and was again reUeved 
by a period of artificial respiration. This was kept 
up more or less continuously for five days, at the 
end of which time the function of the respiratory 
muscles began to return and the child was able to 
breathe without the aid of the apparatus. She made 
a complete recovery and is now in perfectly good 
health. 

A Case of Cardiospasm. — Dr. Godfrey R. 
PiSEK, of New York, said that the occurrence of 
cardiospasm in early liie was still so rare as to 
make it justifiable to report this case. Since adult 
cases might trace their inception to early life or to 
congenital defects, the pediatrist might well con- 
sider these cases worthy of study. Neurotic or 
primary cardiospasm was attributed by some author- 
ities to a contraction of the left crura of the dia- 
phragm, by others to defective innervation, or to 
localized atony of the esophagus. 

The case reported was that of a girl, twelve years 
of age, who first came under observation in Sep- 
tember, 1919. The family and past history were 
negative. When three or four years old the child 
exhibited a strong will and was said to be "tem- 
peramental." This trait grew stronger as she grew 
older ; otherwise she was an outdoor athletic child. 
She had a peculiar appetite, disliking vegetables, 
eggs, and sweets. About a month before coming 
under observation she complained that food choked 



her and at night she had a similar difficulty, com- 
plaining of a strangling sensation. A cough de- 
veloped in connection with the night spasms, un- 
conscious as far as the patient was concerned, and 
upon which codeine had no effect. Physical ex- 
amination revealed nothing abnormal except some 
retraction of the supraclavicular and infraclavicular 
spaces, a slight tremor of the upper eyelids, a ten- 
dency to relaxation of the spine and bowing of 
the shoulders, and evidence of orthostatic albumi- 
nuria. Radiographic and fluoroscopic examination 
confirmed the diagnosis of cardiospasm. After an 
esophagoscopy under general anesthesia a moderate 
dilatation was done, but no anatomical basis was 
demonstrable. • Bougies were passed at about fort- 
nightly intervals until her departure for Florida in 
March of this year. In the South she did well at 
first, but she contracted malaria, lost weight, going 
down rapidly to eighty pounds, twenty pounds below 
normal, and the original symptoms of her cardio- 
spasm returned. She was brought North and care- 
fully examined again. The gastric contents showed 
retention, and the fluoroscopic examination a con- 
siderable dilatation of the esophagus with a smooth 
fusiform constriction at the cardiac end. Bougies 
were passed every fourth day. She was given 
atropine and a measured diet of 3,000 to 3,500 
calories a day, and she gained fifteen pounds in 
twenty-nine days. Whether it would be necessary 
to pass a duodenal tube and give the stomach a 
complete rest for a time was still a question. This 
case showed that it was not so easy to treat this 
condition as one was led to suppose by the literature. 

Congenital Atresia of the Esophagus. — Dr 
Henry L. K. Shaw, of Albany, said he reported this 
case for the purpose of emphasizing the historical 
side more than the clinical. The child gave a his- 
tory of food coming out of its nose, and on attempt- 
ing to pass the stomach tube it went down only a 
short distance. After giving barium the x ray showed 
the esophagus filling, but the barium did not pass 
through to the stomach. Examination of the lungs 
showed them filled with fine rales. The child died 
and at autopsy it was found that the upper third 
of the esophagus ended in a cul-de-sac and had no 
relation to the 4ower part which opened into the 
trachea. A similar case was reported in 1682 and 
another in 1703 by a Dr. Gibson, physician general 
to the British Army and a grandson of Oliver Crom- 
well. Dr. Shaw read this description, which was 
so accurate that it would be difficult to improve, 
upon it today. 

Primary Sarcoma of the Thymus. — Dr. L. 
Emmett Holt, of New York, said this patient was 
a child, six months old, with symptoms dating back 
only four weeks. The parents were healthy, as 
were two other children. This child was small and 
gained in weight slowly, weighing nine and a half 
pounds at the age of six months. The symptoms 
were merely an increasing pallor and slight fever. 
There were minute hemorrhages over the neck and 
extremities. The case was looked upon as one of 
severe secondary anemia of unknown origin. The 



January 1. 1921.] 



PROCEEDINGS OP NATIONAL AND LOCAL SOCIETIES. 



43 



temperature ranged between normal and 103° F. 
As the hemorrhages continued to appear, a trans- 
fusion of blood was given, but was of no perma- 
nent benefit. The child failed rapidly and died. 
At autopsy a thymus weighing thirty-six grams was 
found, which was very large, the upper limit of 
the normal being ten grams. Beside the sarcomatous 
condition of the thymus similar changes were found 
in one of the lymph nodes, in the spleen, and in 
the lungs. The case was interesting because the 
child presented none of the symptoms usually asso- 
ciated with enlarged thymus, and because of the 
rarity of sarcoma of the thymus in infants and 
young children the case was perhaps unique. 

Heart Displacement Apparently Due to Medi- 
astinal Emphysema Following Aspiration Pneu- 
monia. — Dr. E. C. Fleischxer stated that this pa- 
tient, a boy, three and a half years of age, following 
a fall into a sand pile, became wheezy. Four hours 
later he was brought to the hospital with sibilant 
rales over the lungs, both anteriorly and posteriorly. 
The X ray showed no foreign body and no condi- 
tion calling for surgical intervention. The heart 
was displaced slightly to the right. The boy con- 
tracted a definite pneumonia on the left side, in- 
volving the middle lobe. The displacement of the 
heart did not seem to be due to fluid. At the end 
of forty-eight hours a subcutaneous emphysema 
appeared above the clavicle and extended down to 
the pelvic bone. The pneumonia subsided, to be 
followed by a bronchiectasis in the left lung. He 
had a prolonged illness, but the x ray taken five 
months after the accident was to all intents and 
purposes normal. In this case the heart had gone 
rapidly and completely to the right. It seemed 
reasonable to believe that injury during the accident 
had caused air to push through the lung and force 
the heart to the right, and then work its way out 
into the subcutaneous tissues. 

A Case of Lymphosarcoma. — Dr. Charles A. 
Fife, of Philadelphia, said the unusual features 
which prompted him to report this case of lympho- 
sarcoma were: 1. The treatment by x ray of an en- 
larged cervical lymph node, the probable primary 
lesion, on the supposition that it was tuberculous. 
The node had not been excised. There was no 
other evidence of tuberculosis. 2. Wide metastasis, 
within five months of the cessation of rontgenism. 
3. The extensive involvement of the tracheobron- 
chial lymph nodes producing massive exudation into 
the left pleura, but causing no other signs of medi- 
astinal compression. 4. The high, irregular tem- 
perature, extending over a period of one year. 
5. The polynuclear leucocytosis in blood and lym- 
phocytosis in pleural exudates. 6. The tremendous 
enlargement of the spleen and of the liver. 7. The 
varieties of previous diagnoses, including influenza, 
endocarditis, secondary anemia, tuberculosis, adeni- 
tis, leucemia, Hodgkin's disease, and substernal 
empyema. 8. The rapid reduction in size of the 
bronchotracheal lymph nodes, and the improvement 
in the condition of the patient after x ray treatment 
to the mediastinal region. 9. The marked el¥ect of 
x ray and radium on the lymphosarcomatous tissue 
as shown in the pathological specimens. 

The patient was a boy, nine years old, giving a 



negative medical history until his seventh year, when 
a slowly enlarging right cervical lymph node was 
detected. Notwithstanding the removal of tonsils 
and adenoids the gland attained in ten months the 
size of a large egg. After three rontgen treatments 
given in the course of a month the mass became 
the size of a hickory nut, and after twenty treat- 
ments, in fifteen months, the disease was thought 
to be eradicated. The Doy returned about four 
months later with a recurrence and died six months 
after coming under observation. The hemoglobin 
had fallen to thirteen per cent., the red cells to 
500,000, and the whites to 2,000, eighty per cent, 
being lymphocytes. The postmortem diagnosis was 
small and large celled lymphosarcoma. The struc- 
tures involved were the cervical, tracheobronchial, 
and retroperitoneal lymph nodes, the spleen and the 
liver. The chief histological interest lay in the 
fact that the nodes low down in the abdomen where 
they were unaffected by radiation were full of 
typical, active tumor cells, while the lymph nodes 
in rogions treated by x ray or radium showed retro- 
grade changes in the tumor cells, and thus many 
tumor cells were replaced by dense connective tissue. 

The Duct Sign in Mumps. — Dr. David Mur- 
ray CowiE, of Ann Arbor, reported that in ninety- 
seven per cent, of fifty-seven cases of parotid 
mumps a red spot was observed at the orifice of 
the Steno's duct which developed and disappeared 
under the inflvience of the disease. The duct itself 
became teatulated. The detailed description of the 
color change and the duct involvement was given, 
and illustrative cases cited. The sign developed 
early in the disease, sometimes ahead of the swell- 
ing of the parotid, and disappeared when the duct 
returned to normal. The sign was uninfluenced by 
the degree of fever. Submaxillary ducts showed no 
redness when the submaxillary glands were involved. 
Whether the duct sign was pathognomonic of 
specific parotiditis, or was present in other acute 
inflammatory conditions, had not been determined. 
Because of the occasional occurrence of teatulation 
of Steno's duct in a certain percentage of apparently 
normal persons and tlie ocasional finding of red- 
ness of its orifice, careful differentiation should be 
made. The duct sign ^liould be regarded simply 
as corroborative evidence of parotid gland involve- 
ment. 

A Case of Priapism Resulting from Rapidly 
Spreading Malignant Myxosarcoma with Gener- 
alized Metastasis. — ^D'r. David Murray Cowie re- 
ported this case, the unusual feature of it being 
the early age of the boy, nine years. 

Streptococcic Angina with Purpura Hemor- 
rhagica and Multiple Infarcts of the Skin and 
Subcutaneous Tissue. — Dr. Walter R. Ramsey, 
of St. Paul, stated that this patient, two and a half 
years old, was. brought to the city from a distance 
of two hundred miles. His family and past 
history were negative. His present illness began 
with a sore throat two weeks before. After a few 
days there was swelling of both legs and an 
offensive odor from mouth and nose. Upon arrival 
at the office the child was in a moribund condition. 
The skin and mucous membranes were extremely 
pale and there was marked edema about the face. 



44 



PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES. 



[New York 
Medical Journal. 



the eyes being swollen shut. The legs and feet 
were markedly edematous. There were numerous 
petechial areas scattered over the entire body. The 
fauces and tonsils were covered with a foul gray 
membrane, and the entire mucous membranes of 
the mouth, including those of the lips, were gan- 
grenous. The temperature was 104° and the pulse 
was rapid and weak. The condition was so sus- 
picious of diphtheria that 20,000 units of antitoxin 
were given immediately. The culture, however, 
proved negative. The purpura cleared up under 
this treatment. Deep sloughs developed in a few 
days on the right wrist, on both ears, both elbows, 
and on the perineum. The palate sloughed ofif. 
The middle phalanx of the middle finger on the 
right hand sloughed out, and later healed perfectly, 
leaving a finger with one phalanx missing. A dark 
area over the occipital region sloughed out and part 
of the bone also. All these areas healed under 
Dakin's solution, applied four times a day. 

Anaphylaxis Following an Intradermal Protein 
Sensitization Test. — Dr. Henr\ J. Gersten- 
BERGER and Dr. J. H. Davis, of Cleveland, reported 
this case, which showed the following points of 
interest: 1. A boy, seventeen months old, who had 
never received egg in any form, presented an ex- 
treme anaphylactic shock after an intracutaneous 
administration of egg yolk allergen and egg albumin 
in doses of one and two mg. 2. This child, who 
had received cow's milk from his third week of 
life and who had suffered from eczema and asthma, 
showed a negative intracutaneous test to cows' milk 
casein and cows' milk albumin. The intracutaneous 
injection of cows' milk allergen responded within 
twenty-four hours with an indurated and red area 
of infiltration not unlike that of an ordinary positive 
Von Pirquet test, but entirely dififerent from an 
urticarial wheal. 3. This same boy was not sensi- 
tive to other proteins. 4. The first severe anaphy- 
lactic shock on December 8th did not prevent the 
development on December 13th of a second, follow- 
ing the administration of egg yolk allergen five days 
later. 5. The x ray photographs made at dififerent 
intervals on the same day showed a definite wide 
abnormal thymic shadow and again a perfectly nor- 
mal picture. The former, as found by fluoroscopic 
examination, occurred during extreme expiration, 
the latter during extreme inspiration. 6. The thy- 
mus gland, if it really were large in an abnormal 
sense, did not produce the respiratory difficulty in 
a mechanical way. 7. This patient might be a case 
of status lymphaticus and this condition might be 
responsible for his congenital pathological sensitive- 
ness to egg proteins and his anaphylactic reaction. 
If, however, he should be found not to be sensitive 
to other proteins, especially horse serum and horse 
hair protein, the status lymphaticus could hardly be 
accepted as a causative factor in his condition, for it 
would be difficult to imagine how a status lymphati- 
cus could make a child sensitive solely to egg pro- 
tein and not to oats, milk, horse serum or horsehair 
proteins. The child was revived from his severe 
anaphylactic shock by means of subcutaneous injec- 
tions of adrenalin and the use of artificial respira- 
tion. One should always have adrenalin at hand 
while making these tests. 



Has Malt Soup Extract an Antiscorbutic 
Value? — Dr. Henry J. Gerstexberger, of Cleve- 
land, reported that while studying the respiratory 
quotient of scorbutic infants, it was decided for 
definite reasons to feed these infants with Keller's 
malt soup, a mixture which had made for itself a 
record of producing and never curing scurvy. 
During this study three infants with marked and 
severe scurvy recovered unexpectedly in a rapid 
and complete manner. Dr. Gerstenberger discussed 
the factors that might have influenced the antiscor- 
butic content of this special lot of malt soup extract. 

A Brief Report on Lactic Acid Milk. — Dr. 
DeWitt H. Sherman, of Buffalo, gave a report on 
some original work that he and his associate. Dr. 
Harry R. Lohnes, had been doing this last winter 
on lactic acid milks. As a therapeutic food of many 
years' standing'the various accepted reasons for its 
beneficial effect were discussed. At first the good 
results were supposedly due to the Bulgarian 
bacillus. This idea had iDeen stated to be incorrect. 
The second reason was that the increased acidity 
of the gastric contents, as they passed into the duo- 
denum, stimulated the intestinal secretions. This had 
been put aside. The third reason, which at present 
seemed most rational, was that lactic acid was effi- 
cient through Meltzer's law of contrary innervation ; 
that it was productive of good results through the 
increased amplification of the peristaltic wave, and 
by this increased motility, function was increased. 

He compared the relative value of protein milk 
with lactic acid milk and showed some of their 
dififerences. He questioned the extolled value of 
protein milk because its soluble salts were removed 
and its insoluble salts, those of calcium and mag- 
nesium, were in excess. He appreciated the value 
of protein milk in those infants whose tolerance 
for sugars was broken. He laid stress on the acidity 
of the lactic acid milk as a reason for the infants 
refusing it or rejecting it. The desired acidity he 
placed at seventy to ninety, as measured by a deci- 
normal sodium hydrate solution. To keep this acidity 
he gave two original methods for making lactic acid 
milk. The first was to culture the boiled and hence 
sterile milk, and put it away at a temperature of 
85° F., in an ordinary icebox so commonly found 
in the household. It was to remain there over- 
night, and in the morning would be found of 
approximately the correct acidity. It was then to 
be boiled again to destroy the activity of the 
Bulgarian bacillus, and put away on the ice. The 
second method was even simpler. Culture the 
boiled milk, allow it to stand in a warm place, and 
in twenty-four hours the acidity would reach 180 
to 190, possibly 200, an acid reaction of sufficient 
degree to destroy the Bulgarian bacillus. Dilute 
this very acid lactic acid milk with an equal amount 
of sweet milk, and the correct acidity is secured. 
Upon adding the two a fine clotting occurs, and 
when boiling the second time active stirring is 
essential to retain a homogeneous mixture. To 
make the formulae flexible in reference to fat, a 
skimmed lactic acid milk was first used, and as 
indications permitted, whole lactic acid milk was 
gradually substituted for it. 

(To be continued.) 



New York Medical Journal 

INCORPORATING THE 

Philadelphia Medical Journal Medical News 

A Weekly Review of Medicine, Established 18^3. 

Vol. CXIII, No. 2. NEW YORK, SATURDAY. JANUARY S, 1921. Whole No. 2107. 

Original Communications 



THE FAMILIAL DISTRIBUTION OF THE 
MIGR.'MNE-EPILEPSY SYNDROME.* 
By J. Arthur Buchanan, M. D., 

Rochester, Minn., 
Fellow in Medicine, The Mayo Foundation. 

Numerous studies have been made in the attempt 
to prove the origin of the tendencies which lead in 
certain perspns to essential epilepsy- Various sub- 
stances have been incriminated, but as time passed 
all have had to be more or less definitely excluded. 
The impetus to the study of the germ plasm, brought 
about by the publication of Weismann's monograph 
on this basic plasm in the interrelations between 
generations, has stimulated the study of its role in 
the transmission of epilepsy. If epilepsy is her- 
editary the factor which is the determiner of its 
subsequent manifestation must be contained in 
either the spermatozoa or in the ovum, and there- 
fore, as Hippocrates said, epilepsy begins to be 
formed while the fetus is iii utero. 

Mendel preceded all investigators in showing the 
germ plasm to possess the ability of distributing 
.determiners of transmissible characters in certain 
more or less fixed ratios (3). This lead has been 
followed by general biologists ; hundreds of charac- 
ters have been worked out definitely so that a 
breeder can know within very narrow limits what 
the physical make up of the next generation will be. 
Until the present time this subject in the human 
race has received very little consideration, and prob- 
ably only in the hemophilic have we evidence that a 
peculiarity of the human race is definitely segre- 
gated during the manifold changes that take place 
in the development of the fertilized ovum. 

Shortly after beginning my work in the Mayo 
Foundation I was struck with the occurrence of a 
rather fixed numerical ratio between the normal 
and the abnormal in families subject to migraine. 
Also when I carefully took the histories of essential 
epileptics for information concerning the immediate 
parentage, the siblings of the patient, and, when 
possible, concerning the grandparents, I obtained 
cL history of transmitted migraine in a good majority 
of cases. Our endeavors to collect data about sus- 
pected hereditary conditions are not more successful 
because of the belief that if the father and mother 
are clear of any manifestations of the condition 
there is nothing to be gained by carrying investiga- 
tions into the side lines. This is a gross error, 

*Presented for publication November 30, 1920. 



and one which has prevented the collection of more 
ample and accurate data. The father and mother 
may be free of the condition although they have 
the ability to transmit the condition ; they are spoken 
of as the heterozygotes, and it is the study of the 
heterozygotes that necessitates the keenest scrutiny. 
The study of the homozygote, the person with the 
condition, who is pure in the mendelian sense, and 
of the homozygote's family reveals convincing in- 
formation. In the investigation of the heterozygote 
inquiry should be made concerning brothers and 
sisters, brothers and sisters of the immediate pa- 
rents, and the grandparents. Definite notation 
must be made of the number of persons in each 
generation so as to ascertain numerically those who 
have and those who do not have the condition. 

The conception of epilepsy as an expression of 
the mendelian segregation of the germ plasm leads 
to the thought that if such be the case, convulsive 
seizures at various times are physiological for the 
patient. The seizure represents the end of yet un- 
determined cyclic biological processes in the gen- 
eral economy of the subject. The term hereditary 
disease for epilepsy, migraine, or any other condi- 
tion is not correct in the true sense of the word 
disease. The appearance of a true hereditary con- 
dition in man leads to the necessity for the classifi- 
cation of a subvariety of mankind and this sub- 
variety calls for a different physiological interpre- 
tation than that applied to mankind as a whole. 
It is apparent from the findings quoted in this paper 
that in the migraine-epilepsy syndrome we have 
evidences that there is a subvariety of man charac- 
terized by painful or convulsive seizures which 
must be chemical in their substrata. It is impos- 
sible to conceive of the determiner of an hereditary 
character as anything else than a chemical substance, 
since everything that results from the activities of 
the germ plasm is chemical in nature. Given an 
unknown chemical substance in the germ plasm, a 
product must result that is entirely or to a large 
extent dififerent in its physiological chemistry. 

The proof that the epileptic is the possessor of a 
physiological chemistry that is dififerent from that 
which we call normal for man is being demonstrated 
with difficulty hut gradually by numerous workers. 
Binswanger has called attention to certain sero- 
reactions in the epileptic which have a certain de- 
gree of variability with the progress of the condi- 
dition. Thabius and Barbe have found the spinal 
fluid of epileptics to contain extractives below nor- 



Copyright, 1921, by A. R. Elliott Publishing Company. 



46 



BUCHANAN: MIGRAINE-EPILEPSY SYNDROME. 



[New York 
Medical Journal. 



mal : increased ash and chloride content, and de- 
creased albumin content. Allers has found the 
chemistry of the postconvulsive albuminuria asso- 
ciated with an unknown acid production. Tinte- 
mann found that the total acidity of the urine is in- 
creased, and the increase is due' especially to phos- 
phoric and uric acids. The chemical instability of 
the bodily mechanism of the epileptic has been 
demonstrated by Florence and Clement, who were 
able to produce convulsions in the epileptic by the 
administration of ammonium acetate or carbonate, 
unless the patient was under bromide medication. 
These two investigators also found that the essen- 
tial epileptic oxidizes benzene more rapidly between 
attacks than the normal person (during the attacks 
the oxidation is less rapid), and that phenol sul- 
phates appear in the urine sooner in the epileptic. 
Handelsman has proved, in spite of many asser- 
tions to the contrary, that cholin has nothing to do 
with the production of convulsions in the essential 
epileptic. Loewe in the study of urine from epilep- 
tics found a variable amount of undialyzable sub- 
stances. Allers and Sacristan failed to find a nitro- 
gen equilibrium in epileptics, which they were un- 
able to explain. They are also investigating the 
purin metabolism. Trevisanello has found a marked 
anaphylactic reaction in guineapigs treated with 
the blood serum and spinal fluid of the essential 
epileptic, while controls treated with serum and 
spinal fluid of normal persons did not have such a 
reaction. 

A recordable physical difiference in epileptics has 
been described recently by Scripture. The study 
of the melody plot of the voice by a special instru- 
ment has shown that the voice of the epileptic 
presents a diminution or absence of the finer fluc- 
tuations. This inflexibility, apart from the rigidity 
of monotonous speech, does not occur, according 
to Scripture, in any organic condition yet studied, 
and has been used in differential diagnostic tests 
with success. 

Clark has described in many papers the peculiari- 
ties of the epileptic personality. Marsh has re- 
cently called attention to the same condition. But 
one case in which this peculiar type of makeup is 
described is recorded in the Mayo Clinic. This 
patient was also the carrier of the migraine factor. 
I have investigated the types of personality, and I 
am prepared to state that this particular type rarely 
occurs in the patients at the Mayo Clinic. The 
traits of the epileptics with whom we have to deal 
are so excellently described in an article by Ryther 
and Ordway that repetition is unnecessary. It is 
apparent that our epileptics are in temperament, 
education, economic efficiency, and in personal* ex- 
periences identical with those found in Boston 
(Ryther and Ordway), but somewhat different 
from those found in New York (Clark). 

In a recent study of the nature of the transmis- 
sion of migraine it was found that migraine demon- 
strates the segregation of the determiners in the 
germ plasm; it presents a mendelian ratio of 3.08 
to 1 (6). In a previous investigation of migraine 
in relation to epilepsy seventy-five per cent, of the 
128 patients studied had a migraine strain in their 
ancestral or personal history (5). The occurrence 



of such a high percentage of migraine in the study 
of the epileptic led to the investigation of a series 
of epileptics in whom the family history contained 
a definite statement of the number of children, the 
presence or absence of migraine in the family, and 
the presence or absence of epilepsy, with a numer- 
ical statement of the number affected with either 
condition. Forty-six epileptic families were studied 
from the viewpoint of the distribution of epilepsy 
considered as a manifestation of the migraine fac- 
tor, and in order to learn the heritage of the children 
when no history of migraine had been found. The 
families with epileptic parentage were also studied 
in order to learn if they followed the same general 
principle. Either the father or the mother of thirty- 
five patients (seventy-five per cent.) had migraine, 
six patients (thirteen per cent.) had no knowledge 
of migraine or epilepsy in the family, and five (ten 
per cent.) fell in the heterozygote parentage group. 
The forty-six families studied consisted of 262 
children, of whom 198 were normal, and sixty-four 
had epilepsy or migraine, giving a mendelian ratio 
of 3.09 to 1. This ratio is so nearly that obtained 
previously for migraine alone that they can be con- 
sidered identical. Forty- four (sixty-eight per cent.) 
of the sixty-four children had epilepsy, and twenty 
(31.2 per cent.) had migraine; of the latter two 
were the offspring of an epileptic woman mated 
with a normal man. 

Thirteen (twenty-nine per cent.) of the forty- 
four epileptics had migraine as an alternating, pre- 
ceding, or combined condition. The only patients 
with socalled arrested epilepsy had migraine as a 
replacement condition. In the study of the cross- 
ing of two pure strains of migraine it was found 
that all the children from such matings had mi- 
graine. One family was found in which a woman 
with migraine was mated with a man with epilepsy. 
If epilepsy is considered a manifestation of the same, 
basic condition as migraine, all the children in 1:his 
family would be expected to have either migraine 
or epilepsy. All had migraine ; in addition one had 
epilepsy, which alternated irregularly with the 
attacks of migraine. 

The series comprising this study is too small from 
which to draw conclusions, but it is sufficiently 
large to stimulate the belief that the essential con- 
vulsive seizures are a manifestation of the peculiar- 
ities transmitted to persons by the migraine factor. 
It also leads one to suspect that the advice com- 
monly given to epileptics to avoid marriage or not 
to have children will not eventuate in the reduction 
of the number of epileptics, for the basis on which 
epilepsy apparently depends is the person with mi- 
graine who is married without any thought of the 
type of progeny that may result. 

BIBLIOGRAPHY. 

1. Allers, R. : Zur Theorie der postepileptischen Al- 
buminurie, Ztschr. f. d. ges. Neurol, u. Psychiat., 1912, 
Orig., viii, 361-380. 

2. Allers, R., and Sacristan, J. M. : Vier Stoffwech- 
selversuche bei Epileptikern, Ztschr. f. d. ges. Neurol, u. 
Psychiat., 1913, Orig., xx., 305-326. 

3. Bateson, W. : Mendel's Principles of Heredity, E.r- 
p crimen ts in Plant Hybridisation, Cambridge University 
Press, 1909, 317-361. 

4. BiNSWANGER, O. : Die Abderhaldensche Seroreak- 



January 8, 1921.] 



PORTER: ANIMAL AND VEGETABLE PROTEINS. 



A7 



tion bei Epileptikern, Miinchen. vied. IVocliciischr, 1913, Ix, 
2321-2325. 

5. Buchanan, J. A. : A Study of the Hereditary Fac- 
tors of Epilepsy, Minn. Med., 1920, iii, 526-538. 

6. Idem: The Mendelianism of Migraine, Medical 
Record, 1920, xcviii, 807-808. 

7. Clark, L. P. : The True Epileptic, New York Medi-. 
CAL Journal, 1918, cvii, 817-824. 

8. Idem: Treatment of the Epileptic Based on a Study 
of the Fundamental Makeup, Journal A. M. A., 1918, Ixx, 
357-362. 

9. Idem: Is Essential Epilepsy a Life Reaction Dis- 
order? American Journal of the Medical Sciences, 1919, 
clviii, 703-711. 

10. Idem: A Consideration of the Aftercare of Arrested 
Cases of Essential Epilepsy, American Journal of the Medi- 
cal Sciences, 1920, clx, 582-589. 

11. Idem: A Psychological Interpretation of Essentia! 
Epilepsy, Brain, 1920, xliii, 38-49. 

12. Florence, J. E., arid Clement, P. : L'epreuve de 
I'ammoniurie experimentale chez I'epileptique, Comp. rend. 
Acad. d. sc., 1909, cxlix, 462-465. 

13. Idem: L'epreuve de la phenolurie provoquee chez 
I'epileptique, Compt. rend. Acad. d. sc., 1909, cxlix, 368-370. 

14. Handelsman, J. : Experimentelle und chemische 
Untersuchungen iiber das Cholin und seine Bedeutung fur 
die Entstehung epileptischer Krampfe, Dcutsch. Ztschr. f. 
Nerfcnh., 1908, xxxv, 428-432. 

15. Loewe, S. : Untersuchungen iiber die Harnkolloide 
von Epileptikern und Geisteskranken, Ztschr. f. d ges. 
Neurol, u. Psychiat, 1911, Orig., vii, 73-111. 

16. Marsh, C. A.: A Psychological Theory of the Cause 
of Epilepsy, with Special Reference to an Abnormal Mus- 
cular Expression of a Strong Emotional Drive, American 
Journal of the Medical Sciences, 1920, clix, 450-458. 

17. Rvther, Margherita, and Ordway, Mabel: Eco- 
nomic Efficiency of Epileptic Patients, Journal of Nervous 
and Mental Diseases, 1918, xlvii, 321-342. 

18. Scripture, E. W. : The Nature of Epilepsy, Pro- 
ceedings Royal Society of Medicine, 1920, xiii, Section 
in Psychiatry, 18-23 

19. Thabuis and Barbe : La Composition physico- 
chemique du liquide cephalo-rachidien des epileptiques. 
Rev. neurol.. 1913, xxi, 248-253. 

20. Tintemann, W. : Die Bewertung der Befunde der 
Gesamt-Stickstoffausscheidung beim Epileptiker im Inter- 
val!, Ztschr. f. d. ges. Neurol, n. Psychiat., 1914, Orig., xxiv, 
49, 52, 

21. Trevisanello. C. : Untersuchungen iiber das Blut- 
serum und die Cerebrospinalfliissigkeit von Epileptikern, 
Centralbl. f. Bakteriol, 1913, Orig., Ixix, 163-166. 

22. Weismann, a. : The Germ Plasm. A Theory of 
Heredity. New York: C. Scribner's Sons, 1912, 37-468. 



ANIMAL VERSUS VEGETABLE PROTEIN. 

By William Henry Porter, M. D., 
■ New York, 

Professor Emeritus in Pathology and General Medicine, New 
York Post-Graduate Medical School and Hospital. 

To understand thoroughly the protein problem 
is no easy matter. So much so that I do not wonder 
at a physician who, in making a friendly criticism 
of my recently published book ( 1 ) , took exception 
to the emphasis placed upon the utility of the ani- 
mal as against the vegetable protein, and wrote, "I 
cannot follow you." This I fully understand, for 
the simple reason that a complete knowledge of this 
protein problein is the most consummate task in 
connection with chemicophysiology. 

Certain facts, however, stand out clearly, such, 
for instance, as these : First, at the very beginning 
of our life and throughout our existence in utero, 
the animal economy is furnished with animal pro- 



tein only ; Nature must have some reason for this. 
Second, as soon as we are expelled from the uterine 
cavity, the infant is given an animal protein. This 
particular protein, casein, is especially valuable, for 
it is the only known proteid, out of which all other 
protein substances can be produced chemically, 
casein having some forms of amino acids that other 
protein compounds do not contain, and without 
these amino acids nutrition cannot be maintained. 
As for instance, while gelatine is a protein sub- 
stance, it will not by itself furnish nutrition to 
animal life. But if a small quantity of casein is 
added to a large quantity of gelatine, the gelatine 
will become a highly nutritious protein substance, 
and the animal economy will thrive, as it were, on 
gelatine. 

These facts naturally stamp the animal proteins 
as the essential ones. Enhancing the nutritive 
value of* protein by the addition of a little casein 
unquestionably applies to many other protein sub- 
stances, more highly nutritious to begin with than 
gelatine, but less so than casein. If these facts are 
true during intrauterine life and early infancy, they 
ought certainly to be equally so as life progresses, 
and far more so when disease processes have to be 
combatted. 

When the term protein excess is used in connec- 
tion with metabolism, it indicates that more protein 
is entering the blood than the hemoglobin can fur- 
nish and distribute oxygen to reduce completely 
the protein substances. This refers to normal body 
states. For the air sacs al\Vays contain a large 
superabundance of oxygen, assuming the animal is 
breathing in anything like a natural atmosphere. 

When we come to deal with pathological condi- 
tions, the nonreduction may not be due simply to 
an overintake of protein, but involves many very 
complicated conditions, such as deficient produc- 
tion of hemoglobin, a too rapid blood current, a 
too slow blood current, toxic substances in the blood 
current preventing the discharge of oxygen, and 
interference with the power of oxygen to split 
the protein compounds. The two most potent fac- 
tors in defective oxidation, however, are a de- 
creased alkalinity of the blood and a diminished 
supply of available glucose. 

No matter how produced, defective oxidation 
means overproduction of catabolic bodies and a 
reduction in the amount and perfection of the nor- 
mal excretory products. Most notable, and the 
greatest index to iinperfect oxidation of the protein 
substances, is an overproduction of uric acid. Its 
determination is the easiest of all the protein cata- 
bolins, hence it is the most important factor. 

Now we come to the essential ditTerences existing 
between the animal and vegetable protein sub- 
stances as two distinct classes. The animals are 
monomolecular in their construction. On the other 
hand, the vegetable protein substances are multi- 
molecular in their composition. That is to say, the 
molecules are doubled up — how many times is not 
accurately known ; hence the chemist writes after the 
formulae n times, thus presenting at the starting 
point an unknown quantity. The doubling may be 
in the form of a 2, 4, 8, 16, 32, 74, 148, 296 mul- 
tiple, and so on up. This much we do know, that 



I 



48 



PORTER: ANIMAL AND VEGETABLE PROTEINS. 



[New York 
Medical Journal. 



they are many times multiplied, and that they must 
be reduced to a single molecular state before the 
digestive ferments can begin to peptonize them. 

On the other hand the animal protein substances 
have been reduced to the single state by our herbiv- 
erous friends in the animal kingdom, who have 
many stomachs with endless feet of intestine, as 
compared with the human family and other meat- 
eating species. 

The result is, that the ferment bodies in the hu- 
man digestive tract can immediately bring to bear 
their chemical digestive activity on these single 
animal protein molecules and convert them into a 
peptone. Here is where the danger lies in a too 
free use of the animal foods as compared with the 
vegetable protein substances. With the former, 
too much will be peptonized and the blood over- 
loaded with protein compounds, unless the quantity 
ingested is kept well within the physiological limit. 
When so done, however, the strain upon the digest- 
ive energy is kept at -the lowest ebb, while the sys- 
tem is being fully siipphed with constructive ma- 
terial of the animal protein class. 

On the other hand, the vegetable protein has to 
be split all the way down in the digestive canal, by 
its chemical activities, until it becomes a single mole- 
cule like that found in the animal kingdom before 
the peptonizing process can begin. In many in- 
stances this is a long and tedious process. So much 
so, that with the vegetable class from fifteen to 
eighty per cent, of the protein substances contained 
in this class is lost in its transit through the alimen- 
tary Canal. With the animal class the loss ranges 
between two and eight tenths and five per cent., 
thus making the animal class very much more eco- 
nomic from this viewpoint. This loss when the 
vegetable class is used exclusively is often so great 
that constructive nutritive activity cannot be fully 
maintained. 

The overworking of the digestive energies with 
a too abundant vegetable supply tends after a time 
to weaken the digestive energies. This, together 
with the over irritation by the undigested residue, 
and the putrefactive fermentation that is bound to 
follow when the digestive ferments are deficient, 
often becomes a menace to life. All this naturally 
leads to the fact that if one eats too abundantly of 
animal foods alone, or in conjunction with an over 
supply of carbohydrate and fat foods, he can and 
does ver)^ easily exceed the oxygenating capacity 
of the system. This, however, is no excuse for 
choosing a food supply that overtaxes the digestive 
energies, to cut down the protein supply. On the 
other hand, it shows conclusively that the correct 
thing to do is to keep the supply of animal foods 
within rational physiological limits. 

This is what I have always contended, because 
it spares digestive .and dynamic energy, and yet 
furnishes the system with its full ciuota of avail- 
able constructive nutritive material. Even though 
there is this wide difYerence in economic value be- 
tween the two classes, it does not indicate that the 
one class should be used to the exclusion of the 
other. For they both have their good and bad 
points, neither one having all that is perfect for the 
highest grade of nutritive activity. Therefore to 



secure the best balanced food supply, the two 
classes must be used, selecting from the animal 
class chiefly to secure the protein supply, and using 
the vegetables to furnish the salts and socalled 
vitamines. 

. At this point it might be well to say that with 
this protein problem I have been dealing only with 
what may be called constructive proteins ; not with 
the other classes, which are in the nature of acti- 
vating agents, enzymes, and ferment bodies, and not 
directly tissue builders. Neither have I tried to 
contrast the two classes in their many points of 
difference. While it might be interesting more 
fully to prove that the -"^ne cannot be used to the 
exclusion of the other, it would be too wide a 
digression from the main subject of this paper. 

This same physician in his criticism objected to 
the animal class on account of the large amount "of 
poison waste which was in process of elimination 
from the animal at the time it was killed, but the 
elimination of which was checked by his [sic] 
slaughter," and complained that we were compelled 
to take this poison waste when we obtained our 
protein supply from a "juicy steak." 

This bugaboo about poison waste and its en- 
trance into the system on account of its being at- 
tached to the animal fibre, has always seemed a 
pretty farfetched argument, excepting the leuco- 
maine and ptomaine poisons, practically developed 
after the death of the animal and also produced 
from decomposed and dead vegetable protein; both 
of which conditions, however, are very rarely met 
with. 

The reason that this poison waste danger is 
merely a scare, is proved by the fact that under 
normal circumstances only a fraction of one per 
cent, of any effete material is ever found in the 
blood, lymph, or tissues of the body. But their 
natural place is in the excreta eliminated from the 
animal economy and chiefly found outside the body, 
not within. This is a fact which does not seem 
to be generally recognized. In this connection it is 
reasonable to suppose that most animals when killed 
are in a fairly normal condition. Hence, very little 
poisonous material is taken with the carcass from 
the slaughter house to the retail market. 

Having gained the knowledge that no matter what 
the origin of the protein molecule is, and that it 
must be a single one before the digestive ferments 
can act upon it, the next question is, What happens 
to these single protein molecules? We find that 
they all, no matter what their origin, have to be 
transformed by the action of the digesting ferments 
into that particular form of protein known as a 
peptone, this being the only form in which a pro- 
tein substance can enter the epithelial cells lining 
the intestinal canal. We also know that this par- 
ticular protein, peptone, is a most deadly poison. 
We also know that in its passage through these cells 
it loses its identity and toxicity and emerges on the 
other side of the cell into the blood stream in three 
other forms of protein substances, namely : serum 
albumin, globulin, and fibrinogen, and that serum 
albumin is composed of three other di.stinctive pro- 
tein bodies. How many more there may l)e is yet 
to be determined. Thus, that which was a single 



January 8, 1921.] 



ROUT: PREVENTION OF VENEREAL DISEASE. 



49 



molecule on entering the epithelial cell lining the 
intestinal tract, appears in the blood in live distinct 
forms. 

Thus this protein peptone molecule becomes as 
distinctive as H2O does, no matter what the origin 
of either may have been. 

With this imderstanding of the digestive act, and 
when the digestive secretions are normally produced 
both as to quality, composition and amount, there 
is no putrefactive or abnormal fermentation taking 
place in the alimentary tract, and there is no toxicity 
of the system from this source. Thus we find that 
nature is quite capable of maintaining all her power 
to keep these horrible poisons well out of the sys- 
tem, and conseciuently we do not suffer from the 
much dreaded calamity. 

Let down, for any reason, the full power of the 
natural digestive ferments, and at once the micro- 
organisms of all kinds that produce pathogenic fer- 
mentation will get busy generating abnormal prod- 
ucts, some of which may have a high toxicity, which 
latter will poison the system, but not because an 
animal protein was used instead of a vegetable one. 
All fruits, and especially those highly charged 
with acids and saccharine compounds, are very 
prone to ferment and irritate the intestinal mucous 
membrane. Likewi.se all highly indigestible foods 
act as irritants to the mucous membrane. This 
irritation augments the secretion of mucus from 
the intestinal wall, which is often thick and tena- 
cious, and this mucus is in a large measure the 
culture medium in which the pathogenic micro- 
organisms thrive. Hence this class of foods should 
be studiously avoided if we do not wish to c"ourt 
real danger. 

Therefore my rule has been, know your chem- 
istry and physiology, and the composition and di- 
gestibility of all foods. Then select those most 
easily digested, least fermentable and irritating to 
the intestinal canal. Select from both animal and 
vegetable kingdoms according to the result to be 
obtained, and in such manner that the oxygenating 
capacity will not be exceeded. Then we will be 
following pretty close to Nature's law or laws; in 
fact, so nearly that we can get almost any result we 
desire to attain. 

REFERENCES. 

1. Porter: Eating to Live Long. Reilly & Lee Companv, 
Chicago, 1920. 

46 West Eighty-third Street. 



Further Research in the Treatment of Hyper- 
tension. — Leslie Thorne Thorne {Practitioner, 
May. 1920) says that in cases of hypertension, 
whether sclerotic or not, the blood pressure lis 
always lowered by immersion in a Nauheim bath, 
whether that bath is of the still or the effen'escent 
variety. Even an advanced condition of arterio- 
sclerosis does not counterindicate this treatment. 
The Nauheim baths are useful not only for treat- 
ment, but also for the purpose of differentiating 
between sclerotic and presclerotic hypertension, as 
the effect of the baths upon the blood pressure 
differs materially according to the condition of 
the vessel walls. 



PREVENTION OF VENEREAL DISEASE. 
By Ettie A. Rout (Mrs. Hornibrook), 

London, England. 

In the New York Medical Journal for October 
30, 1920, Dr. Satterthwaite cjuotes me as follows 
(New York Medical Journal, October 9, 1920) : 

In fact, Miss Rout asserts that i)roi)hylaxis is success- 
ful when properly applied in only two thirds of the cases, 
as shown by. the returns of the .'\merican, Canadian, and 
Australian armies. 

What I actually said was : 

Wherever prophylaxis was properly applied, at least two 
thirds of the cases of venereal disease were eliminated. . . . 
In particular cases enormously better results than this were 
attained. 

The War Department, Washington (General 
Order No. 135, December 23, 1919), says: 

Its use (that is, the use of prophylaxis) appears to re 
duce the liability to venereal disease among those exposed 
to about one third of what it would be without prophylaxis 

Prophylaxis, or disinfection, of course does not 
fail at all (practically speaking) when properly 
applied. Failure to apply disinfectants reduces the 
efficacy of the system of prophylaxis. This failur^i 
among Paris leave men was one third due to care- 
lessness, one third to drunkenness, and one third to 
willful infection. 

During the latter part of the war, venereal dis- 
ease had to be classified as a "selfinflicted wound." 
Diseased women were known to charge more for 
sexual relationship than clean women. Such was 
the state of mental distraction into which some men 
were driven by the ordeal of Ixittle that they actually 
paid diseased comrades to infect them for the pur- 
pose of securing a temporary release from the 
firing line. Failure to protect the men was due at 
times to the entire absence of disinfectants. I know 
by experience that the distribution of portable dis- 
infectants, and the spread of a knowledge of self- 
disinfection, was responsbile for preventing much 
disease; but the critics of the socalled packet system 
never tell us that there was frequently no system 
at all and still more frequently no packets. You 
see, there was a war on at fhe time ! The actual 
fact is that the British Army succeeded in dis- 
tributing an average of one calomel capsule per 
soldier per annum. The Au.stralian and New 
Zealand troops on leave before 1918 were poorly 
provided with the means of disinfection; in 1918 
not more than half the men on leave actually got 
their issue of disinfectants (except those going to 
Paris) ; after the armistice, most of our men were 
absent without leave at various times, and travelled 
very widely, so that it was impossible to provide 
them with disinfectants. I lectured to some 25,000 
of our soldiers during May and June, 1919, and 
found that approximately ten })er cent, had been 
provided with disinfecting packets — ninety per cent, 
admitted going on leave' without protection. 

The following is a digest of a paper read 
by an American doctor (then in the Canadian 
Medical Service), viz., Captain Walker, Medical 
Officer in care of British Medical Report Centre, 
Pepiniere Barracks, Paris, before the Venereal Dis- 
ease Conference arranged by the American Red 
Cross in the Hotel Continental, Paris, in April, 1918: 



50 



ROUT: PREVENTION OF VENEREAL DISEASE. 



[New York 
Medical Journal. 



During August-Se])leml)cr, 1917 — sixty days — a 
little over five thousand officers and men came on 
leave to Paris; in 1,038 of these men venereal dis- 
ease developed — over twenty per cent. Leave to 
Paris was then closed. Leave was reopened on 
November 8, 1917. and at the same time there was 
opened the Medical Report Centre, where all British, 
Australian, New Zealand, South African, and 
Canadian soldiers on leave to Paris had to report 
before they could draw pay in Paris. Calomel 
tubes were offered, the soldiers having the option 
of refusal. The number who refused was approxi- 
mately one to the thousand. From November to 
March, 60,000 tubes were issued, and 29,000 
prophylactic treatments given. 

Captain Walker stated that since his own enlist- 
ment he had been responsible for issuing over 
100,000 tubes and giving 53,000 treatments, and 
that he had yet to find one man who took his tube 
of calomel ointment, used it as directed, and re- 
ported for prophylactic treatment in a properly con- 
ducted centre, who had nevertheless contracted 
venereal disease. 

The actual result of the preventive measures 
described was that from November 8, 1917, to 
March 31, 1918, the infection rate of over twenty 
per cent, was reduced to less than three per cent.— 
one per cent, was due to drink, one per cent, to 
willful infection, and one per cent, to carelessness 
and conceit. 

Speaking in regard to licensed houses. Captain 
Walker said that he had not found one case of 
venereal disease contracted in a licensed house in 
the city of Paris, and he could only suppose that 
the people who were responsible for putting the 
licensed houses in Paris out of bounds knew noth- 
ing at all about the real facts of the case. In the 
licensed houses of the city of Paris during the 
year 1917. only five cases of venereal disease were 
contracted, and in 1918, up to April 20th (the day 
he was speaking), there had not been one case of 
venereal disease contracted in a licensed house in 
the city of Paris. (Of course, the Paris houses 
were well conducted- and medically supervised.) 

Out of two hundred women arrested on the 
streets of Paris during the month of April, 1918, 
over twenty-five per cent, were found to be infected 
with venereal disease. But this was much better 
than in 1917. In the months of November and 
December, 1917, the French authorities had a round- 
up on one boulevard of seventy-one women, of 
whom fifty-five were infected. A few days later, 
about a hundred women were arrested, and ninety- 
one per cent, were infected with venereal disease. 

Nevertheless the Americans put the Paris licensed 
houses out of bounds to their soldiers, and the men 
consorted with the much more dangerous women 
of the streets. The British order in this respect 
was never enforced. I suggested the following 
working compromise to the English L. of C. officers 
and it was vmofficially accepted : 

1. The British authorities in Paris do not know 
where the French licensed houses are ; 

2. It is not their duty to find out ; 

3. They have no staff for ascertaining this knowl- 
edge. 



Experienced military and medical officers knew 
that the licensed houses made the least dangerous 
provision for the nomial sexual needs of the men, 
and we knew that we could not extinguish or para- 
lyze the sexual instincts of the majority of the 
soldiers, however much we tried to encourage con- 
tinence. But we knew also that all the irregular 
intercourse could not be confined to the licensed 
houses, and therefore portable disinfectants and 
prophylactic stations were required ; in fact, all 
means of controlling venereal disease are required 
— social, moral, medical, and legal. 

Dr. Satterthwaite, on the other hand, apparently 
condemns medical and legal protections, although 
he says : 

We cannot, of course, abolish venereal diseases now. for 
the present sources of contagion must necessarily con- 
tinue for an indefinite time to be a danger to the public, 
even if no new instances of the disease should occur. More- 
over, we can never prevent clandestine relations. 

To admit this, and oppose personal disinfection, 
seems to me an untenable position. 

The answer to those who wish to rely only on 
moral prophylaxis, is that this method of controlling 
venereal infection has already broken down; that 
is why venereal disease has spread so widely. 

The answer to those who wish to rely on licensed 
houses only is that in Paris these did not of them- 
selves prevent some twenty per cent, of British 
and overseas troops on leave becoming infected in 
August-September, 1917. 

The answer to those who wish to rely on prophy- 
lactic stations only is that even in wartime these 
alone did not prove sufficient to control venereal 
diseases — the imcontrolled diseased women in Eng- 
land succeeded in contaminating our men faster 
than we could instruct the men and provide the 
means of disinfection. 

Finally, let me express my own opinion that 
although there are many objections — moral, social, 
and medical — to the licensed house system of Paris, 
it proved nevertheless infinitely preferable to the 
unlicensed house system of London. This French 
system, supplemented by our own issue of portable 
disinfectants to Anzac soldiers (Australiafis and 
New Zealanders), and aided most generously and 
most valuably by the American Red Cross Dis- 
pensaries and the American Army Prophylactic 
Stations (all of which made our soldiers welcome 
to their medical benefits) was responsible for the 
fact that Paris gave us the lowest rate of infection 
in 1918, whereas London gave us the highest. 

May I also, without offense, point out that such 
an inquiry as Dr. Satterthwaite asks for would be 
most useful in dispelling many illusions with regard 
to the American Army statistics? For example, in 
a book recently sent me for review, viz., Sanity in 
Sex, by William J. Fielding, published by Kegan 
Paul, the following excerpts are taken from a cir- 
cular issued by the Surgeon General of the American 
Army: 

A. During the fifty-three weeks ending September 27. 
1918, there have been 178,204 venereal disease cases reported 
under treatment in the United States Army in France. 

B. Reports indicate that approximately eighty-five per 
cent, of this number entered the army already infected, and 
that approximately fifteen per cent, of all cases reported 
were contracted after enlistment. 



January 8, 1921.] 



BLAIR: ANTIXARCOTIC LECISLATION. 



51 



And Mr. Fielding says this "showed a great 
improvement in venereal health in comparison with 
men of similar ages, in civil life." He also quotes 
from the Social Hygiene Bulletin, September, 1919, 
as follows : 

It is usually said that of all the cases of syphilis and 
gonorrhea among soldiers, five sixths were contracted in 
civilian life and only one sixth after the men were in uni- 
form. A careful study of all the new cases of venereal dis- 
eases at five large cantonments which the Surgeon General's 
Office has made, shows the army in a still more favorable 
light. 

The cantonments selected were Lee, Virginia ; Dix, New 
Jersey ; Upton, New York ; Meade, Maryland, and Pike, 
Arkansas, for the year ending May 21, 1919. During this 
year 48,167 cases were treated. It was found that ninety- 
six per cent, were contracted before entering the army, and 
only four per cent, after. Army officials claim that these 
figures indicate decisively how easy it is to prevent the 
spread of venereal diseases when a determined effort is 
made to do so. 

I quite agree that venereal disease can be pre- 
vented and ought tcJ be prevented, and that the 
American efforts, so far as they went, were admir- 
able — particularly in Paris. But the American 
medical examiners were really not so lax and in- 
competent as to allow from eighty-five to ninety- 
four per cent, of the venereal disease cases to slide 
into the Army undetected. The explanation is that 
American soldiers were court martialled if they 
contracted venereal disease, and heavily fined, unless 
they swore that the disease was a recurrence — that 
they had had venereal disease before they joined 
the army. Naturally that is what they did swear. 
They could not be punished for the mechanical 
consequences of civil acts The figures are all right, 
but the facts on which the figures are based are 
incomplete and inaccurate. 

From computations based on the report of the Provost 
Marshal General on the first draft, it appears that there 
were 445,000 syphilitics and 2,225,000 men infected with 
gonorrhea among those registered who were not then 
called, 

says Mr. Fielding. If the American doctors de- 
tected all these cases, and missed some eighty-five 
per cent, to ninety-six per cent, of the Army cases, 
one cannot help wondering if there were any really 
uninfected young men in America ! And are we 
expected to believe that the Americans as civilians 
are the most immoral and as soldiers the least im- 
moral of all men? This kind of argument makes 
.the American Medical Service look inefficient and 
ridiculous, whereas actually it was the most efficient 
and serious among all the Allied Armies. Similarly 
the social services connected with the American 
Army were the admiration of us all — for their 
unfailing kindness, their broad humanity, their un- 

' .\t the American Red Cross Conference in Paris, in April, 1918, 
Captain Walker, M. O. i/c British Medical Report Centre, Paris, 
said that in his opinion there were twice the number of officers 
concealing the disease than there were reporting it, and that to get 
at the actual number of infections in other ranks he firmly believed 
the official figures should be doubled. 

Speaking on July 2, 1920, Dr. J. H. Sequiera (of the London 
Hospital) said: 

.\fter the armistice it was well known that there was a large 
amount of concealed venereal disease in the Army. It was obvious 
that men would not run the risk of missing early demobilization by 
reporting that they were suffering from venereal disease. Colonel 
Harrison demonstrated this in an ingenious manner by what he calls 
the complication index. It was found that while there was a drop 
in the number of cases of primary syphilis, which can be concealed, 
there was a rise, in the number with secondary symptoms, which 
cannot be hidden. Similarly, gonorrhea, in its early stages was not 
reported, while the proportion of cases with epididymitis, etc., which 
incapacitates a man, increased in number. 



selfish generosity, and their thorough efficiency. 
But the tide of racial contamination swept on — 
arrested practically not at all except by disinfection ; 
and that tide was infinitely worse, as we now know, 
than can ever be revealed by military statistics.' 
But this standing ground for future efforts is sure: 

1. Clean persons can be kept clean by disinfection. 

2. Diseased persons can be prevented from .spread- 
ing contamination. 

3. Under civilian conditions all persons desire to 
avoid venereal infection. 

Thus, in spite of the disharmony between the 
present social and economic conditions and the nor- 
mal sexual needs of men and women, racial health 
can be maintained; the rest is a matter of evolution. 



PRESENT AND CONTEMPLATED ANTI- 
NARCOTIC LEGISLATION.* 

By Thomas S. Blair, M. D., 
Harrisburg, Pa., 

Chief, Bureau of Drug Control, Pennsylvania Department of Health. 

In a letter recently received from Dr. Frederick 
R. Green, secretary of the Council on Health and 
Public Instruction of the American Medical Asso- 
ciation, I find this comment : "It is all right to dis- 
cuss the question of the treatment of drug addic- 
tion and whether or not it is an actual disease. 
These are purely scientific questions for discussion 
in technical organizations. The important thing 
from a social and executive viewpoint, however, is 
to consider practical methods for controlling the 
traffic in habit forming drugs. I think we are very 
well agreed on this and as to the methods which 
should be followed. I do not, of course, in any 
way sympathize with the ideas of some of our more 
extreme members that physicians should be immune 
from all restrictions. On the contrary, I can see no 
reason why the physician, as a citizen, should not 
be subject to the same restrictions for the public 
good that we are constantly urging on laymen in 
the form of public health measures ; but I also be- 
lieve that all restrictions on both physician and lay- 
man .should be the smallest amount necessary to 
accomplish the desired object. The present method 
seems to involve a large amount of annoyance with 
a minimum amount of restriction ; what we want 
is just the opposite. 

"The trouble with the Harrison law is that it 
is a legal evasion. It attempts to regulate traffic in 
habit forming drugs by means of a revenue meas- 
ure. It is all right to control the importation of 
these drugs by Federal taxation but I can see no 
legal obstacle to placing the distribution, after they 
are once admitted to this country, in the hands of 
the United States Public Health Service to dis- 
tribute through legitimate professional channels to 
those who have any legitimate need for them, and 
in such amounts for all proper uses. This, of 
cotirse, would be a new function for the Public 
Health Service to assume, yet its supervision and 
control of serums is very closely analogous to such 
work." 

*Read before the Philadelphia County Medical Societv, November 
10. 1920. 



52 



BLAIR: ANTINARCOTIC LEGISLATION. 



[New York 
Medical Journal. 



This quotation from Dr. Green is very suggestive, 
and is in line with recent thought ; and the propo- 
sition to place the distribution of narcotic drugs 
in the hands of the United States Public Health 
Service would render necessary a government 
monopoly, as it were, in narcotic drugs, none but 
the government or its appointed agents being al- 
lowed to import opium and coca leaves and deriva- 
tives and preparations thereof. As these agents are 
not, in the form of the crude drugs, produced in 
the United States, it is perfectly feasible to invest 
the Federal government with this power, and it is 
a fact that there would not be the difficulty con- 
fronting the government that there is in the en- 
forcement of the Volstead act, which aims to con- 
trol the production, importation, distribution, and 
use of alcohol and alcoholic beverages. 

A governmental report (1) shows that the per 
capita usage in the United States, figuring all educts 
to an opium basis, is thirty-six grains a year for 
every man, woman and child in the Union, without 
taking into consideration smuggled in supplies. It 
is evident that largely unnecessary supplies are 
coming into the country. The 1919 report of the 
Bureau of Drug Control of the Pennsylvania De- 
partment of Health shows that the per capita com- 
ing into Pennsylvania through legitimate channels 
on an opium basis was about twenty-four grains 
a year. 

A recent survey of the public hospitals of this 
commonwealth, and in which all opium educts 
were figured to an opium basis, shows a per capita, 
consumption in the public hospitals of the state of 
only about three grains of opium a year; that is, a 
hospital treating one thousand patients in the year 
1919 used for those patients in the course of the 
year three thousand grains of opium, estimating 
all educts to an opium basis. This same report 
showed that the per capita usage in the practice of 
the medical profession at large outside of hospitals 
was about fifteen grains a year, or five times the 
per capita usage of the hospitals. 

Thus it will be seen that legislation to curb the 
opium and other narcotic menace is necessary, but it 
is a difficult matter for me to speak on this subject 
purely from the point of view of Pennsylvania. 
The menace is a national one, and national legisla- 
tion is necessary. Furthermore, it. is necessary in 
any present or prospective state legislation so to 
shape it and its administration and enforcement as 
to be cooperative with the Federal efl^^orts, as the 
work is one work, and the Federal and state work- 
ers should be fully in harmony. 

This is imperatively necessary ; first, from the 
legal point of view, for as regards legislation of 
parallel nature for the same purpose, Federal legis- 
lation takes precedence over state legislation ; sec- 
ond, while the law is important, its administration 
is more important, and there are so many practical 
points involved in the handling of this problem that 
little substantial result can be obtained without the 
utmost of agreement between Federal and State 
enforcement officers. 

I am not at all prepared to say that the Harrison 
act is insufficient from the point of view of the 
United States Internal Revenue Bureau ; indeed, I 



feel that from this point of view, the Harrison 
law is a very good piece of legislation, but from 
the point of view of the physician, of the retail 
druggist, the dentist, the veterinarian, and the legal 
and other persons endeavoring to suppress drug 
addiction, the Harrison law is insufficient, nor can 
it be otherwise than such, because of the fact that 
the Federal power cannot, within a state, exercise 
the police power that the constituted authorities of 
the commonwealth can exercise ; hence, there is a 
place for state legislation to supplement the Fed- 
eral enactment. 

A serious effort has been made by the Secretary 
of the Treasury and the Commissioner of Internal 
Revenue to patch up the deficiencies of the Harri- 
son law by means of court and treasury decisions 
and internal revenue regulations. Under the cir- 
cumstances, a certain amount of this is necessary, 
but it imposes a great degree of annoyance antl 
bookkeeping upon professional persons handling 
narcotic drugs, and the propaganda of the American 
Medical Association, as expressed in the letter of 
Dr. Green, is the result of much conference with 
the several interests involved, and in my view, opens 
up a way of escape from the harshness and annoy- 
ance of treasury decisions and internal revenue 
regulations ; in other words, the distribution of nar- 
cotic drugs, if placed in medical hands, that is, in 
the control of the United States Public Health Ser- 
vice, would tend to render unnecessary a large part 
of the detailed regulations and the bookkeeping and 
record entries required of professional people ; 
therefore, from the medical point of view, legisla- 
tion along the lines suggested by Dr. Green is a 
consummation devoutly to be wished. 

Now, from the state point of view, permit some 
considerations : 

The Pennsylvania Ant "narcotic Act has now been 
tried out in practical administration ; numerous ac- 
tions have been brought before the courts, and no 
marked defects have appeared in this law, which, 
in the first instance, was very wisely drawn, except 
that the law, as now on the statute books, does not 
give sufficient police power to inspectors in the Bu- 
reau of Drug Control as regards the service of 
warrants of arrest and search in the case of the 
drug peddler and the other criminal elements vio- 
lating the law. These people have no stated places 
of business, and unless arrests are made promptly, 
ofttimes on sight, when violations are witnessed, 
the evidence is destroyed and the people disappear.- 
It is aimed to correct this weakness in the law at 
the next session of the legislature. So far as physi- 
cians, dentists, veterinarians and druggists are con- 
cerned, the law is adequate, as these people have 
stated places of business, maintain records, and are' 
easily traced, so that in the event of violation of 
the law they can have explanation made to them, 
warning served, or in the event of arrest, the jusual 
machinery already provided for by the law is en- 
tirely adequate. 

I do not see any occasion for a revision of the 
Pennsylvania Antinarcotic Act except as regards 
this one thing, namely, increased police power. 
There is, however, need for control of certain other 
drugs, more especially hydrated chloral, cannabis. 



January 8, 1921.] 



BLAIR: 



AXTIXARCOTIC LEGISLATION. 



53 



certain ether preparations, such as Hoffmann'^ 
drops, Hoffmann's anodyne, and golden tincture, 
and perhaps to a Hmited degree as involves some 
of the synthetic somnifacients. This proposed 
legislation should be of such character as to be 
satisfactory to the Pennsylvania Department of 
Health and to the State Board of Pharmacy, and 
should be enforced jointly by these two organiza- 
tions. The matter is now under consideration. 

As justification thereof, permit me to say that 
there is a growing addiction to hydrated chloral, 
promoted largely by certain proprietary medicines 
that should not be dispensed except on the pre- 
scription of a professional man. There is also a 
seriohs menace from ether, especially in the mining 
regions. The Polish miners drink ether if they 
can get it, and as that is not usually available, they 
buy Hoffmann's drops and Hoffmann's anodyne, 
sold throughout the mining districts in practically 
every grocery store and a few drug stores. They 
add this to coffee, becoming intoxicated from the 
ether and alcohol, and many accidents in the mines 
have occurred from such intoxication. There is 
also need to control cannabis for the reason that 
this drug is added to tobacco and is smoked, more 
especially in South America, but this menace is 
reaching the United States, and the'' smoker usually 
becomes insane within two years. 

The question of the control of synthetic somnifa- 
cients involves many difficulties, especially since 
there is legitimate sale for some of these agents in 
the drug stores. However, since prohibition, or 
alleged prohibition, has come, 'many men accustomed 
to alcohol are buying veronal and taking it in exces- 
sive doses, causing a form of intoxication and 
stupor that persists for forty-eight hours. A few 
deaths have occurred in Pennsylvania from such 
indulgence, and I understand that numerous deaths 
have also occurred in New York state. 

Now, as regards legislation aimed to control or 
to take care of the drug addict, there is a most 
admirable habit act on the statute books of Pennsyl- 
vania, whereby a judge of quarter sessions can, on 
due complaint and evidence, commit a drug addict 
to any proper hospital or asylum for a period not 
to exceed one year, for care, treatment, and cure. 
The defect in this law is that no provision is made 
for indigent addicts, a provision that is made in 
the law providing for the erection of a state insti- 
tution for the treatment of alcohol and drug in- 
ebriates. Revision of the habit act in conformity 
with the special act governing the proposed insti- 
tution has already been prepared whereby the drug 
addict, if indigent, will be taken care of at the 
expense jointly of the state and of the county from 
which he comes. 

Now, as regards this proposed institution, the 
matter is in the hands of a commission, and they 
have purchased a tract of ground in Cumberland 
county, 524 acres in extent, and there remains in 
the treasury approximately $135,000 for the prepa- 
ration of this ground, the erection of buildings, 
etc., but no appropriation has been made for the 
maintenance of the institution once it is built. Plans 
have been drawn by the engineering division of the 
Department of Health, which provides for the 



erection of buildings on this tract that would cost 
not to exceed $150,000. That is as far as the 
matter has gone W the present time. 

In connection with it, I was instructed to make 
a survey of public institutions throughout the 
United States, and , 1 rendered a lengthy and elab- 
orate report on this subject. This report, which 
aimed to give nothing but facts, was somewhat 
discoiiraging, owing to the fact that practically 
every effort made as regards the conduct of a' public 
institution designed exclusively for the treatment 
of alcohol and drug inebriates has been a failure, 
and, at the present time, these special institutions 
have been closed. There are many reasons that 
may be assigned for failure, the principal one being 
incompetent •management, due to insufficient salaries 
being paid to the personnel. Another and a very 
important reason for failure was that practically 
all of these institutions admitted persons on volun- 
tary commitment, which has universally been an 
entire failure. The only form of commitinent at 
all effective is a legal commitment whereby the 
inmates are brought under absolute control. There 
are also certain psychological reasons promoting 
the failure of these institutions, but the ^ greatest 
one of all is the fact that these people, when cured, 
as -quite a large proportion of them are, almost 
immediately revert to their habit again, once they 
are discharged. So far as I have been able to fol- 
low up the patients who have been discharged from 
such institutions as cured, I think I am able to say 
that ninety per cent, of- them lapse within six 
months. Therefore, there is little encouragement 
\in opening public institutions until after the laws 
are ^o drafted and their administration so definite 
that the great quantities of unnecessary narcotics" 
in the hands of the more ignorant element in the 
medical profession, and in the hands of peddlers 
as well, are shut off. 

I am obliged to say that comparatively little 
permanent success has resulted from the treatment 
of the psychotic class of addicts, except in the psy- 
chopathic wards of hospitals for the insane, and 
there, in Pennsylvania and elsewhere, quite a 
degree of success has been attained. 

I do not wish to be regarded as lacking at all in 
humanitarianism, but from two years' practical 
experience in administering the Pennsylvania law 
I am forced to the conclusion that too much senti- 
mentalism is indulged in as regards the drug addict. 
The physician sees him only in his personal relation- 
ship with him, while the Bureau of Drug Control 
sees him in his relationship with the almost inevit- 
able two, three, or four doctors treating him at 
the same time. The physician who has registered 
the drug addict under Section 8 of the Pennsyl- 
vania law is usually honest. The addict rarely is, 
and I must confess that of the thousands of addicts 
of various classes registered in the Bureau of Drug 
Control as under the care of private practitioners, 
not two per cent, of them have been cured, though 
a much larger proportion have been reported as 
cured. These supposedly cured persons almost 
inevitably appear on our records again, so that so 
far as the treatment of addicts by the private phy- 
sician is concerned, I am most pessimistic. There 



54 



ROSENBLUTH: EAR CONDITIONS IN AMBULATORY PATIENTS. ^'"""^ 

Medical Journal. 



are, of course, a few physicians temperamentally 
adapted to the handHng of these cases, but these 
physicians are few indeed. The man whose sym- 
pathies are practical instead of on the surface, who 
has a hard fist and controls with a rod of iron the 
addicts imder his care, may succeed. The average 
practitioner makes a gloomy failure in his efforts 
to control the drug addict. Therefore, it is no 
wonder that it is demanded that institutional care 
be provided for these people. 

From my careful study of the situation, I am 
much opposed to the building of a large and elab- 
orate institution for the exclusive care of drug 
addicts. I do not think it possible, under present 
conditions, for such an institution to be a success, 
for reasons that would require a long paper of 
itself to elaborate. In general, it may be said that 
the- grouping together of drug addicts in an insti- 
tution brings about much the same results as their 
grouping together in any section of a city, and 
whatever care is provided after they are taken off 
the drug, which is a very easy matter with the 
average addict, this care must be of a nature to 
build them up physically, mentally, and morally, 
increasing their power of resistance. This involves 
industrial work, and a life under proper environ- 
ment. I am, therefore* of the opinion that the 
special institution provided for should be a small 
one. largely industrial, the inmates kept under 
absolute control, legally committed, and arrested 
ancf brought back if they escape. Furthermore, I 
would have committed rd such an institution only 
the hopeful cases, and those who, after hospitaliza- 
tion and being successfully taken off the drug, need 
a period of building up nnder proper environment, 
with a reasonable degree of physical work. 

As involves the element congregated in certain 
sections of our cities, the addicts who are in jail 
and out again, off the drug and on again, who 
drift from place to place, committing crime and 
becoming more and more vicious, this class of per- 
sons, in my view, should be put in houses of cor- 
rection, or work houses, and compelled to earn their 
way. I am wholly out of sympathy with senti- 
mental views concerning these people. They are 
a drag on society, worthless to themselves and to 
the state, and they drift to the cities away from 
smaller communities where control is more easy, 
adding to the already vicious element in the slums, 
and becoming a menace to themselves and society 
at large. To spend sympathy and large sums of 
money on these people in the following out of 
idealistic methods of control is entirely futile. They 
are a police problem and the municipal police and 
health officers should cooperate in breaking up all 
of the nests of vice these people inhabit, putting 
them under such definite restraint that it will 
become generally known throughout the vicious 
element that drug addiction, for which there is no 
justification from incurable disease existing in the 
j)erson, is a vice, if not a crime, and will be con- 
trolled the same as other vices and other petty 
crimes. 

As involves the legal control of the drug peddler, 
the federal laws are adequate, but their enforce- 
ment is difficult and the personnel employed is 



altogether too small to accomplish results. With 
amendment proposed to the state law, we should 
be able to do more in the future than we have 
accomplished in the past. My own personal view 
is, as regards these people, to organize a man hunt, 
rim them down like rats to their holes, dragnet the 
sections that they inhabit, show them no quarter, 
hunt them out without fear or favor, and punish 
every one of them arrested to the full extent that the 
law permits. It is only by such radical treatment 
and educating the community to the point of view 
that these are the lowest and most debased class of 
'criminals, worthy of nothing but the full and rigid 
enforcement of the law, that we will stamp out 
this menace. These people are not the class played 
up in fiction as picturesque characters, brilliant and 
full of mental resource; on the contrary, they are 
a debased and sordid lot, cunning to the last degree, 
unprincipled and full of vicious resource; but with 
an adequate enforcement of the law, not only by 
the officers specifically charged with the enforce- 
ment of the drug laws but also by every policeman 
and constable in the state, they can be suppressed, 
and it is necessary to cultivate public opinion to 
the point of justifying this sweeping and radical 
enforcement of the drug laws against this class 
of people. 

REFERENCES. 

Traffic in Narcotic Drugs, U. S. Treasurv Department 
1919. 

403 North Second Street. 



SERIOUS EAR CONDITIONS AND COM- 
PLICATIONS IN AMBULATORY 
PATIENTS.* 
By M. Rosexbluth, M. D., 
New York, 

Eye Department, Vanderbilt Clinic; Ear Department, Manhattan 
Eye, Ear, and Throat Hospital; Chief of Out Patient, Ear, Nose, 
and Throat Department, Lebanon Hospital. 

When a life endangering complication develops in 
the course of a disease, the patient usually becomes 
too sick to continue as an ambulatory patient; in 
fact, our suspicion that a serious complication has 
developed in an ambulatory patient is usually 
aroused by the fact that, with more or less sudden- 
ness, symptoms have appeared that completely 
incapacitate him and force him to bed. So gener- 
ally true is it that dangerous complications announce 
their presence by making the patient very sick that 
not only the layman but also a large proportion of 
medical men often fail to suspect or recognize their 
existence, just because the patient is walking about 
and does not complain very mtich or at all. The 
ear, more than any other organ of the body, is 
prone to the development of grave complications 
with which the patient may still be up and about, 
in constant danger of losing his life as a result of 
it. Many patients die every .year from such com- 
plications which were either never recognized at all 
or recognized too late, or were only accidentally 
discovered at the autopsy. Many of these patients 
might have been saved if the condition had been 

o 

•Read before the Bronx County Medical Society, February 18, 
1920. 



Janu.-.ry s, 1921.] ROSENBLUTH: EAR CONDITIONS IN AMHULATORY I'ATIENrS. 



55 



recognized in tirhe, when proper treatment could 
still have been effective. For that reason it is 
important for us to do two things : First, recognize 
that there are many such serious life endangering 
ear complications that may exist in patients who 
are still walking about. Secondly, acquaint our- 
selves with all symptoms that point to or even 
faintly suggest the development of such a compli- 
cation, so that by timely intervention the patient's 
life may be saved. 

These complications can be divided, on an 
anatomical basis, into three groups, as follows : 
1. Those developing in the middle ear and mastoid, 
including the venous sinuses ; 2, those developing in 
the labyrinth ; 3, those developing in the brain, in- 
cluding meninges. 

MIDDLE EAR COM PLICATIOXS. 

Cholesteatoma. — This is the name given to the 
mass of debris made up in the cavity of the middle 
ear, consisting of broken down bone, epithelial cells 
and secretion,- with cholesterin crystals. As this 
mass grows it causes the absorption of the bony 
wall of the middle ear cavity against which it 
presses. In this way it may break through the 
tegmen tympani and produce intracranial complica- 
tions, i. e., meningitis or brain abscess ; or, by pro- 
ducing absorption of the bony capsule of the laby- 
rinth it may produce a fistula in the labyrinth or 
an acute diffuse labyrinthitis ; or it may produce 
a sinus phlebitis through caries or necrosis of the 
sinus plate of the temporal bone. They may exist 
for years without any symptoms, or may produce 
a feeling of heaviness and pressure on the corre- 
sponding side of the head, headache, and dizziness, 
without the presence of any acute inflammatory 
phenomena. The diagnosis is made positive when, 
on microscopical examination, the small gritty lumps 
that come away in the irrigating fluid are found 
to possess the characteristic cholesteatomatous ap- 
pearance and structure. Treatment is radical 
mastoidectomy. 

Facial paralysis. — Facial paralysis of otitic origin 
is next to be considered, not only because to the 
patient it is a very serious matter when half the 
face is paralyzed, but also because when this paraly- 
sis is of otitic origin, it is sometimes the expression 
of a very serious bone necrosis taking place in the 
middle ear. For that reason when a facial paralysis 
occurs in a person who has a chronic running ear, 
it is very important to determine whether it is of 
the ordinary rheumatic type, which is not dangerous 
to life, or whether it is of otitic origin, when it is 
the expression of a life menacing pathological 
condition. 

The differentiation can nearly always be made by 
doing a caloric test on the labyrinth of the sup- 
purating ear. If it is of otitic origin, the labyrinth 
will be "dead" and nonfunctionating, so that douch- 
ing the ear with cold water (68° F.) will not pro- 
duce nystagmus to the opposite side, nor with warm 
water (110° F.) produce nystagmus to the same 
side, because on account of the close proximity of 
the semicircular canals, particularly the horizontal 
one, to the horizontal portion of the facial canal, 
the labyrinth has nearly always been destroyed by 
the same process of bone necrosis that has pro- 



duced the facial paralysis. i he indication is for a 
thorough radical mastoid operation plus labyrinthec- 
tomy. In contradistinction, a facial paralysis oc- 
curring with an acute middl? ear condition is not 
of grave significance. It is then gcneraUy due to 
a dehiscence in the bone of the facial canal, and 
disappears with the subsidence of the middle ear 
condrjion. 

I'>u)ic necrosis. — This is another serious condition. 
Its existence can be supposed when, in a running 
ear, there is the development of pain, most intense 
at night, persistent foul discharge, and granulations. 
The diagnosis is positive if carious bone can be seen 
or felt with the probe, or sequestra are discharged. 
These sequestra not infrequently are made up of 
one or more ossicles, portions of semicircular canals, 
or cochlea. Such a process often leads to intra- 
cranial complications and calls for a thorough 
radical mastoidectomy, if the labyrinth is still unin- 
volved ; if it is involved, a labyrinthectomy must 
also be done. 

Mastoid complications. — A subperiosteal abscess 
may exist in a patient who is still ambulatory, and 
even an acute mastoiditis may develop with little 
disturbance to the patient throughout the whole 
course of its development. In chronic running ears 
chronic mastoiditis not infrequently occurs, where 
at operation the mastoid is found infiltrated with 
pus or granulations, or is sclerotic. These are 
dangerous conditions, because they may give rise to 
sinus thrombosis, meningitis, brain abscess, or laby- 
rinthitis. 

Sinus disease. — In connection with the sinus,' the 
patient may be walking about with a perisinou,s 
abscess, presenting only a few symptoms of a mild 
grade of infection, or no symptoms at all, when, 
as often happens, the sinus is protected by a thick 
wall of granulation tissue. A swelling of the mas- 
toid over the region of the emissary vein, when 
present, is characteristic. Sooner or later it will 
invade either sinus or cerebellum, or both, if not 
attended to. Besides this, patients sometimes walk 
about with actual sinus thrombosis, with chills and 
fever, and such cases have been incorrectly treated, 
for malaria or miliary tuberculosis. 

LABYRINTHINE COMPLICATIONS. 

Labyrinthitis. — Perilabyrinthitis and circum- 
scribed labyrinthitis may manifest themselves in 
attacks of dizziness ; or there may be a labyrinthine 
fistula which also is marked by attacks of dizziness, 
but where, in addition, the fistula test is positive, 
a nystagmus being produced by a sudden increase of 
the air pressure in the middle ear. 

Then there may also exist a latent diffuse sup- 
purative labyrinthitis, where, although the patient 
has no symptoms, the diagnosis can be made from 
the fact that the patient has total end organ deaf- 
ness and that the static labyrinth gives negative 
reactions to the caloric test. The existence of this 
condition is very dangerous. Latter day knowledge 
of this subject has taught us that it very frequently 
is responsible for meningitis or brain abscess, and 
also that many of the cases of meningitis that 
formerly seemed to develop in some obscure way 
and carried oif the patient- after a mastoid operation, 
were the result of the extension of this latent sup- 



56 



GILBRIDE: WOODY OR LIGNEOUS PHLEGMON. 



[New York 
Medical Journal. 



purative process in the labyrinth to the meninges. 
Nowadays, every careful ear surgeon does a caloric 
test on the ear to be operated on for radical mas- 
toid, to determine the existence of labyrinthine 
reactions in the ear and thus exclude the existence 
of a latent suppurative process in the labyrinth ; 
if this test elicits no reactions from both the 
horizontal and vertical canals of the ear about to 
be operated upon, a radical mastoidectomy would 
be insufficient ; a labyrinthectomy would also be 
necessary. 

BRAIN COMPLICATIONS. 

Abscess in the brain. — In connection with the 
brain there may exist in ambulatory patients, either 
an abscess in the cerebrum or a cerebellar abscess. 
Their existence may never be known when of small 
size, or sometimes even when of fair size, until 
accidentally discovered at autopsy after the patient 
has died either from some other disease or from 
rupture of the abscess into the subdural space or 
ventricles. At other times the patient may walk 
around with symptoms directing suspicion to the 
existence of an abscess in the brain, as, for in- 
stance, headache, various degrees of change in the 
appearances of the disc, usually neuritic in type, and 
more frequent in cerebellar than in cerebral abscess ; 
and in cerebellar abscess also nystagmus, ataxia, and 
interference with the normal pastpointing reaction, 
on testing the labyrinth, in the extremities of the 
same side as the afifected cerebellar hemisphere. In 
such patients we may be able to get the corrobora- 
tive history of the initial stage or stage of develop- 
ment some time back. Macewen states that at this 
stage there is always a chill or rigor, high tempera- 
ture and severe headache. The symptoms are of 
short duration, the fever and headache subsiding in 
a few days, leaving the patient in good condition, 
or perhaps immediately followed by symptoms of 
intracranial pressure. This stage is unquestionably 
often supposed to have been la grippe. 

Meningeal involvements. — In the meninges the 
following conditions may exist in an ambulatory 
patient: Chronic pachymeningitis, whose existence 
is discovered at autopsy when the patient dies from 
an extension to the pia or from some other disease ; 
extradural abscess, when sacculated, the diagnosis is 
very difficult or impossible. A helpful point is the 
coming and going of threatening symptoms of 
meningeal irritation after a sudden discharge of a 
large quantity of pus from the ear. If left to itself, 
it produces fistulse in the dura with leptomeningitis 
running a rapidly fatal course. Pachymeningitis 
externa : By this term Politzer designates the con- 
dition observed in large perforations of the tegmen 
tympani and confined to the outer surface of the 
dura. It really does not differ from an extradural 
abscess. It may exist without any symptoms. One 
finds, sometimes, at the radical operation, quite ex- 
tensive areas of the dura of the middle cranial fossa 
lying freely exposed and covered with thick granu- 
lations or exudate without any previous symptoms 
of meningeal irritation. 

These are the serious ear conditions and compli- 
cations that may exist in a patient who is still up 
and about. Perhaps some other conditions might 
also properly have been included under this heading. 



Of course no attempt was mad^ to draw a com- 
plete clinical picture of the way in which every 
condition mentioned presents itself at all times. 
When present, many of these conditions frequently, 
and some generally, produce such marked symptoms 
and make the patient so desperately sick that it is 
inconceivable for the condition at such time to be 
unrecognized or at least suspected. It is the inten- 
tion of this paper to call attention to the fact that 
so many serious ear conditions and complications 
may exist with little or no disturbance to the 
patient, and to call attention to those few symptoms 
when present at such time, a recognition of which 
will help diagnose or direct suspicion to the exist- 
ence of the condition which may often mean the 
saving of a life. And because so often patients 
with these conditions do not connect the symptoms 
with their ear condition and apply to the general 
practitioner for relief, it is the duty of the general 
practitioner to acquaint himself with the symptoms 
of these conditions in the ambulatory patient, so 
that he may not overlook their existence. He 
should also always bear in mind that a patient who 
has a chronic running ear presenting symptoms of 
whatever nature, unless very evidently accounted 
for by 'Some disease entirely unconnected with the 
ear, is safest in the hands of an otologist trained 
to recognize this con'dition and its complications. 
31 East Seventy-second Street.. 



WOODY OR LIGNEOUS PHLEGMON 
OF RECLUS.* 
With a Report of Two Cases Occurring 
in the Thigh. 

By John J. Gilbride, A. M., M. D., 
Philadelphia, Pa. 

Reclus in 1893 first described a hard swelling that 
occurred in the neck, and in his publication he 
reported five cases of what he called woody or 
ligneous phlegmon. Woody phlegmon is a chronic 
inflammation affecting connective tissue, fascia and 
muscles. It is characterized by extreme hardness 
which shows little tendency to suppurate. 

While -in the cases reported by Reclus the 
phlegmon occurred in the neck, that author stated 
that the condition could occur in the right iliac 
fossa. In three cases reported in the literature it 
occurred during the course of chronic appendicitis. 
One of the patients, whose history I shall give, had 
chronic appendicitis. Appendectomy was performed, 
which was followed in six months by woody 
phlegmon of the left thigh and this in turn was 
followed by acute osteomyelitis of the right femur. 
Many, if not most, of the cases reported in the 
literature are those where woody phlegmon occurred 
following operation. This latter aspect of the 
disease has been described and a full bibliography 
given by W. W. Grant, of Denver, Col. (1). 
Fasana (2) records cases where the disease occurred 
in the foot and in the gluteal region. 

Previous ill health and trauma are predisposing 
causes and the disease occurs generally after middle 

*Read before the Philadelphia County Medical Society, November 
26, 1919. 



January 8, 1921.] 



GILBRIDE: WOODY OR LIGNEOUS PHLEGMON. 



57 



life. However, a number of cases have been re- 
ported vi^here it occurred in individuals fifteen or 
twenty years of age. The exciting cause is infec- 
tion with or without trauma. Bacteriological ex- 
aminations made in these cases have shown that 
many varieties of bacteria have been reported 
present, all of attenuated virulence. 

Duse (3) reports the case of a boy fifteen years 
of age, in whom woody phlegmon occurred in the 
left upper abdominal quadrant two and a half 
months after an infected herniotomy wound had 
healed, and records the following observation : 
Incision was made the full length of the growth ; 
no pus was found but a pale rose colored fluid was 
discharged. Tissue removed for histological ex- 
amination showed inflammatory new growth with 
some leucocytes and many plasma cells. Cultures 
showed small, white gram negative staphylococci 
which produced no effect on animal inoculation. 
The patient left the hospital with general and local 
conditions unchanged. The author states that in 
previous studies the following bacteria have been 
reported, namely, Klebs-Loeffler bacillus, pseudo- 
diphtheria, streptococci, bacillus proteus, staphylo- 
cocci, white and yellow, all of attenuated virulence. 

Todd, of St. Joseph, Mo., has reported a case 
of woody phlegmon that occurred in the abdominal 
wall of a young woman. It was supposed to be 
due to a fall in 1909. This tumor of boardlike 
hardness was first observed in March, 1910. An 
operation was performed, removing the central part 
of the tumor on May 16, 1911, with no appreciable 
improvement. The patient had lost twenty-one 
pounds in weight in one year. On account of the 
loss of weight and her weakness a diagnosis of 
sarcoma had been made, which later proved to be 
an error. The pathological report showed inflam- 
matory changes in the muscle with a large amount 
of granulation tissue lymphoid plasma cells and 
polymorphonuclear leucocytes, complicated with 
tiny abscesses. Charles A. Powers, of Denver, 
Col., has described this condition (5). 

The onset of woody phlegmon is gradual and its 
progress is slow. A hard, indurated swelHng is 
noticed, which progressively extends. Its outline is 
sharply defined, but. according to Fasana (2), it 
may be diffuse or nodular. The usual signs of 
acute inflammation are absent. Swelling is present, 
but there is no redness of the skin, little or no 
pain or tenderness, and fever is slight or absent. 
The skin is involved late, if at all, in the course of 
the disease. The hardened indurated area increases 
very slowly over a period of months or even one 
or two years. Its occurrence in the neck is of more 
serious import than when it occurs elsewhere in the 
body. This is true not only on account of the 
complications which may arise in the neck, but also 
on account of its extension. There is little ten- 
dency to suppurate, which would be the most fortu- 
nate outcome in terminating the case. 

Both of my patients believed they had rheuma- 
tism. The masses were not connected with the 
bone, periosteum, or skin ; lymphatic involvement 
was not demonstrable. Grant says the lymph nodes 
are not usually affected. Fasana (2) uses the term 
hyperleucocytosis, and says that its presence is in 



favor of a diagnosis of phlegmon. In the early stage 
of this condition it has been mistaken for cancer or 
sarcoma. The possibility of lues, actinomycosis, and 
tuberculosis, must also be borne in mind. One can 
readily appreciate the difficulty of making a differ- 
ential diagnosis between woody phlegmon and 
sarcoma. This is especially -true in cases in which 
the onset has been insidious, or where there has been 
a history of trauma. The cases which follow 
operation should be less confusing. The histories 
of my cases are as follows: 

Case I. — Female, white, married, fifty-one years 
of age, born in the United States, housekeeper by 
occupation. She consulted me on January 3, 1917, 
because of pain in the right thigh and leg, which 
was increased by walking. Her previous history 
was negative, except that she had had an attack of 
acute appendicitis in September, 1916, and was 
confined to bed for one week. Her bowels were 
constipated, and "she always had a bad stomach." 
Pain in the right thigh was worse at night. 
Physical examination did not show any tenderness 
over the course of the anterior crural or obturator 
nerves ; the posterior branch of the latter pierces the 
capsular ligament and sends branches to the knee 
joint. Neither was there tenderness along the 
course of the sciatic nerves. Full extension of the 
right leg and thigh caused slight pain in the right 
lower abdomen. There was tenderness at McBur- 
ney's point. Urine was negative, blood pressure 
130 mm. systolic, 80 mm. diastolic. A diagnosis of 
chronic appendicitis was made. I performed an 
, appendectomy on the patient at the Medicochirur- 
gical Hospital on January 27, 1917; recovery was 
uneventful. 

The patient consulted me again on October 10, 
1917, complaining of a large mass in the inner side 
of the left thigh. Her attention was first called to 
this condition by the presence of slight pain in the 
left thigh in June, 1917. Later in September and 
again in October of the same year she had been 
under treatment by her physician for rheumatism. 
The mass in the thigh had been increasing in size 
and caused her some alarm. On examination I 
found a large swelling, nearly twice the size of my 
fist, in the inner side of the left thigh. The mass 
was slightly movable and nowhere adherent. The 
skin was normal in color. I made a diagnosis of 
chronic inflammation, bearing in mind the possi- 
bility that the mass might be malignant, i. e., sar- 
coma. There was no sign of suppuration. The 
patient hesitated about permitting an operation. 
However, she later consented, and on October 27, 
1917, a deep incision was made into the mass. 
There was no pus, only a dark brown bloody fluid ; 
the wound was packed and dressed antiseptically. 
A culture taken from the wound showed staphylo- 
coccus pyogenes aureus. The mass gradually 
diminished in size. About November 10, 1917, she 
began again to have pain in the right thigh and leg. 
The pain was only intermittent at first, but later 
it became almost constant. She improved in a few 
days, and on November 15, 1917, the patient was 
able to be up and about the house, but on November 
27, 1917, she was again confined to bed on account 
of the severe pain in the right thigh. The right 



58 



MADDREN: TRAUMATIC INTRAMUSCULAR OSSIFICATION. 



[New York 
Medical Journal. 



femur, especially uver tlie lower end of the shaft, 
was tender to pressure. Her temperature at that 
time was 101° F., and there was an increase in 
leucocytes. A diagnosis of acute osteomyelitis of 
the right femur was made and operation advised, 
but the patient refused to give her consent until 
December 16, 1917, when I operated on the right 
femur at the RIedicochirurgical Hospital on Decem- 
ber 17, 1917. A small abscess containing about a 
fourth of an ounce of pus was exposed at the jimc- 
tion of the lower and middle third of the right 
femur. Culture from the abscess showed Staphylo- 
coccus pyogenes aureus. Recovery was slow ; the 
wound healed by February, 1918. 

An autogenous vaccine was made and used in 
her case. She has since remained well. Since the 
appendectomy she has not had any further trouble 
with her stomach and she also said that the head- 
aches from which she had suffered several times 
a week for years past had also disappeared. 

Case II. — Female, white, married, aged thirty- 
five, born in the United States, housekeeper. She 
consulted me on July 15, 1917, stating that about two 
months before she had noticed a swelling in the right 
thigh, which had been gradually getting larger, so 
that she had difficulty in walking. She was a rather 
delicate woman, and poorly nourished. Examination 
of the mass in the thigh showed it to be about the 
size of an orange. The color of the skin was nor- 
mal. The mass was movable, slightly tender, and 
nonadherent. None of the signs of acute inflam- 
mation were present, and there was no lymphatic 
involvement. The mass was incised and drained. 
Culture showed staphylococcus pyogenes aureus. 
In the course of two weeks the mass had disap- 
peared. Before the operation I gave her an injec- 
tion of ten thousand units of diphtheria antitoxin. 
She also was given an autogenous vaccine. 

Case III. — Female, white, aged thirty-six years; 
married, no children, housekeeper by occupation ; 
born in the United States. She was referred to me 
in February, 1901. She had a hard, boardlike, in- 
durated mass in the left lower abdomen, involving 
the abdominal wall and extending into the left iliac 
fossa. It was regular in outline and there were no 
signs of acute inflammation. The woman was pale, 
weak, and very poorly nourished. She had lost 
about twenty-five pounds in weight during the pre- 
vious three months. Her appetite was poor and 
her bowels were constipated. There was a slight 
elevation of temperature — 99.2° F. — pulse rate 84 
a minute ; uranalysis was negative ; hemoglobin 
seventy-six per cent. (Dare). Pelvic examination 
showed that the uterus was not involved. Although 
at that time I did not know anything about woody 
phlegmon, I made a diagnosis of inflammatory in- 
duration due to a low grade infection and probably 
having its origin in the sigmoid flexure of the colon. 
I expected on making an incision to find pus deeply 
situated, but did not discover any foci of suppu- 
ration. I then concluded that the mass was malig- 
nant. However, after subsequently learning some- 
thing aboi.it woody phlegmon, I was satisfied that 
this was the correct diagnosis. The patient had 
been confined to bed for six weeks before I saw 
her; she died five weeks later; no autopsy. 



TREATME.VT. 

Extirpation may be attempted, if practicable, but 
it is rarely practicable. In the event of being unable 
to extirpate the mass, free incisions should be made 
into the mass, also around its periphery. These 
latter incisions are made for the purpose of limiting 
the extending area and also as an aid in promoting 
absorption. In these cases hot, moist antiseptic 
dressings should be used, and over the dressings 
a hot water bottle applied, which should be changed 
at frequent intervals. An autogenous vaccine should 
be made and injected. One should give special at- 
tention to the hygienic, dietetic, and medicinal treat- 
ment, as these patients are usually in a weakened 
and poorly nourished condition. Preparations of 
iron and arsenic are valuable. From what we know 
of this disease, its course is very prolonged and the 
disease may be serious, especially when the neck is 
involved. Should I encounter another case of 
woody phlegmon I shall employ blood transfusion, 
which I believe would be valuable. I injected 
diphtheria antitoxin in one of these patients and it 
brought about a marked improvement. The disease 
appears insidiously ; it follows operations, especially 
abdominal operations, and it may be caused by the 
presence of a foreign body. 

REFERENCES. 

1. Grant, W. W. : Ligneous Phlegmon of the Abdomi- 
nal Wall, Journal A. M. A., April 5, 1913, p. 1039. 

2. Fasana : Gacctta degli ospcdali e elle Cliniche, Oc- 
tober 20, 1912, p. 1345. 

3. DusE : Contributo ullo Studio del flemmone lignes di 
Reclus, Gacctta denli ospedali e elle Cliniche, 1910, xxxi, 
p. 625. Quoted by Grant. 

4. TonD, Luther Anson : Obscure Infiltration of the 
Abdominal Wall, Journal of the Missouri Medical Associa- 
tinu. February, 1912. 

5. Powers, Charles A. : Woody Phlegmon of the Neck 
of Reclus, Journal A. M. A., July 29, 1911, p. 365. 

1934 Chestnut Street. 

TRAUMATIC INTRAMUSCULAR 
OSSIFICATION. 
By Russell F. Maddren, M. D., 
New York. 

The term traumatic intramuscular ossification 
was first used by Morley (1) in reporting a case 
of what is often called traumatic ossifying myositis. 
Morley took exception to the old name because • it 
implied an unfounded pathology for this interest- 
ing lesion, and in his article he brought forward 
experimental pfoof of the correctness of his clinical 
deductions. Traumatic intramuscular ossification 
is the rather uncommon seqitence of a single severe 
contusion. In not one of the two hundred cases 
collected by Shere (2) was there any break in the 
skin. It should be sharply dififerentiated from true 
myositis ossificans of the progressive type that starts 
early in life, usually in the muscles of the neck or 
liack, and progresses irregularly and intermittently. 
There is also a third type of muscle and tendon 
ossification which is the result of slight but fre- 
c|uently repeated trauma. 

REPORT OF A CASE. 

History: On March 31. 1920, S. M. (No. 293), 
aged twenty-five, a blacksmith's helper, reported to 



January 8, 1921.] 



MADDREN: TRAUMATIC INTRAMUSCULAR OSSII-ICATION. 



59 



me, complaining of lameness and severe pain in his 
right leg. He said that while holding a heavy swage 
under a steam hammer his hands had slipped just 
as the hammer came down. The handle of the 
>wage, torn from his grasp, struck him so forcibly 
on the front of the right thigh jthat he was felled. 
He got up unaided and was able to bear his weight 
on his right leg, but walking caused severe pain. 

Examination: There was an area of tenderness 
at the lower anterior part of the, right thigh, and 
some swelling. Partial or complete fracture of 
the femur was ruled out by the use of the fluoro- 
scope and by comparative mensuration of both legs. 
Diagnosis, contusion. 

Course: The man was transported to his home 
and treated there until April 8th. The treatment 
used was rest, elastic compression, and first cold and 
subsequently hot applications. Both the pain and 
the lameness gradually disappeared, and on April 
8th the patient returned to his work.. He was dis- 
charged, cured, on April 12th. 

Second examination: On April 28th, S. M. re- 
ported again, complaining of pain in his right thigh 
and inability to flex the knee completely. There 
had been no additional trauma. Upon examination 
a firm, sensitive, immovable mass about the size of 
an egg could be distinguished. It appeared to be 
growing from the femur about six inches above 
the patella and a little to the outer side. His tem- 
perature was normal. Tests and examinations for 
tuberculosis and lues were negative. A skiagram 
showed a mass of new bone three and a half inches 
long by one and a half inches thick, at about the 
middle of the femur, but the picture did not appear 
to be that of ossifying periosteal sarcoma. A print 
of the X ray plate was submitted to Dr. James 
Ewing, of New York, who said that he did not 
think the lesion was malignant. He advised against 
excising a part of the mass for microscopic diagnosis. 

Course: For ten days cacodylate of soda was 
given subcutaneously every other day in increasing 
doses. Commencing on May 3rd, x ray treatments 
were started and repeated twice a week in as heavy 
doses as was considered safe, and at the same time 
the patient was put upon potassium iodide three 
times daily. Probably this treatment had very little 
eflfect upon the lesion. The man was kept very 
quiet at home until June 7th, by which date tender- 
ness had almost disappeared and he returned to 
light work. Passive motion was gently forced every 
day and he was encouraged to exercise his leg. 
Another skiagram on June 28th showed approxi- 
mately the same condition that had been found 
previously. The mass was no larger. By the 
middle of July the leg could be flexed to a right 
angle and the man was working regularly at his 
trade of blacksmith's helper. 

PATHOLOGY. 

Morley called attention to the fact that under 
certain conditions a severe blow might loosen the 
pferiosteum from its bony attachments, lacerating 
and contusing it in the process. In his original 
article he showed pictures of traumatic intramus- 
cular ossification experimentally produced in the 
rabbit. At the same time that the periosteum is 



injured the overlying muscle is contused and some 
of its fibres are torn. Bleeding occurs from the 
denuded bone and torn periosteum, and osteoblasts 
in a free and possibly ameboid state pass out from 
the bone and find in the mixture of pulped muscle 
and extravasated blood an almost ideal culture 
medium wherein they thrive and produce new bone. 
The mass of new formed bone may be small or 
may be so large as to occupy almost the entire 
muscle in which it lies. In Outland and Clenden- 
ing's case (3) the area of ossified tissue measured 
ten inches by three inches by two inches. 

BIOLOGY. 

In the records of the German Army over a period 
of ten years, Schultz (4) found 233 cases of trau- 
matic intramuscular ossification. The most inter- 
esting and curious fact that his research brought 
out was that, of these cases, in all but three the 
lesion was either in tlie quadriceps femoris or 
brachialis muscles. (Of the three exceptions, two 
were in the masseter and one in the pectoralis 
major.) 

The highly specific localization exhibited in these 
cases is probably due to the fact that nowhere else 
in the body excfept in these two particular places can 
there be found a considerable area of easily detached 
periosteum overlaid by a thick pad of muscles. 
Murphy (5) points out that in both of these regions 
there is a "broad, smooth, convex area of bone, 
covered by periosteum, that is loosely attached and 
readily srtipped oflf owing to the absence of tendin- 
ous insertions." 

DIAGNOSIS. 

According to Bloodgood, myositis ossificans seen 
before bone begins to be formed can only be dif- 
ferentiated from sarcoma under the microscope. 
It is improbable, however, that a patient could be 
induced to consent to disarticulation at the hip 
joint a few days after having bruised his thigh 
however severely. A month or more after the 
injury the character of the lesion can be better 
established by a skiagram than by a microscopic 
section. 

Occasionally severe contusions are followed by 
an aneurysmal type of sarcoma, but these cases 
usually present such a striking clinical picture that 
they could not be confused with anything but ful- 
minating osteomyelitis, which they simulate exactly 
until pulsation becomes palpable. I have seen one 
such sarcoma prove fatal in twenty-eight days from 
the. original injury. 

Socalled rider's bone and the ossific deposits 
sometimes found in the deltoid muscles of infantry 
soldiers are both the results of frequent slight 
mechanical irritation and are true occupational 
diseases. 

In the progressive type of ossifying myositis, the 
first complaint may have been of painful swellings 
in the muscles of the back, neck or thorax, but the 
differential diagnosis is usually very easy. Accord- 
ing to DeWitt (6) and others, .seventy-five per cent, 
of such cases show microdactylism. This peculiar- 
ity, first noted by Helferich in 1879, was not present 
in the only case of the multiple progressive type 
that I have had the opportunity of studying. 



60 



IaXDSMAN: diagnostic VALUE OF PROCTOLOGIC AL EXAMINATIONS [New York 

Medical Journal. 



TREATMENT. 

Unless serious disability exists and persists un- 
improved by active and passive exercises, surgery 
is contraindicated. In 1905, R. Jones (7) advised 
operation in all cases of traumatic intramuscular 
ossification, but in a letter to Rickman Godlee (8) 
in 1911 he said; "The simplest looking mass in the 
bend of the elbow is a difficult problem to deal with 
surgically, and more than once I have wished that 
I had let it alone." 

If operation is decided upon, the physiology of 
bone must be remembered. Simple excision is 
almost certain to be followed by recurrence, because 
the normal periosteum has been torn loose and no 
longer fulfills its function as a limiting membrane 
for osteoblasts. In Morley's case there was a 
recurrence in three weeks. At the second opera- 
tion he successfully transplanted fascia lata onto 
the denuded bone to prevent adhesions between 
bone and muscle and to form an artificial limiting 
membrane. 

If not operated upon, the mass usually ceases to 
grow after a time and may even become smaller, 
owing to reabsorption of bone similar to that seen 
in some cancellous osteomata (9). Treatment with 
radium, the rontgen ray, or potassium iodide, may 
possibly accelerate this process of consolidation, and 
does no harm if carefully controlled. The patient 
should be encouraged to exercise in an attempt to 
restore the normal range of motion. Very fre- 
quently vigorous exercise leads to complete func- 
tional recovery after a considerable lapse of time. 

REFERENCES. 

1. MoRLEY, J.: Traumatic Intramuscular Ossification, 
British Medical Journal, xi, 1475-77, December 6, 1913. 

2. Shere, O. M. : Myositis Ossificans Traumatica, Jour- 
nal A. M. A., Ixv, 1012-6, September 18, 1915. 

3. OuTLAND, J. H., and Clendening, L. : Recurrent 
Myositis Ossificans Traumatica, Interstate Medical Journal, 
xxii, 2, 1093, November, 1915. 

4. ScHULz, H. : Ueber Myositis ossificans in der Armee, 
1897-07, Deutsche Milit'drartsl. Zeitschrift, xxxix, 4, 129-45, 
1910. 

5. Murphy, J. B. : Traumatic Intramuscular Ossifica- 
tion, Surgical Clinics, vol. v, No. 4, 765-771, 1916. 

6. De Witt, L. : Myositis Ossificans, American Journal 
of the Medical Sciences, cxx, 295, September, 1900; Nico- 
LAYSEN : Norsk Magasin fiir Lagevidensk, xv, 4, 1900. 

7. Jones, R. : Archives of the Rontgen Ray, 1905 (cited 
by Godlee). 

8. GoDLFE, R. : Myositis Ossificans, Proceedings of the 
Royal Society of Medicine, Series of 1910, 154. 

9. Battle and Shattock : Cancellous Osteomata, Pro- 
ceedinqs of the Royal Society of Medicine, Series of 
1908, 83. 

616 Madison Avenue. 



Specific Diagnosis and Treatment of Acute 
Lobar Pneumonia. — Lesley H. Spooner (Boston 
Medical and Surgical Journal, February 26, 1920) 
says that thirty per cent, of the cases of acute lobar 
pneumonia are due to Type I organism. An im- 
mediate diagnosis of type is essential for the early 
administration of specific sera. The use of poly- 
valent sera is irrational and unjustified. Careful 
use of Type I senmi in Type I pneumonia is safe, 
and has reduced the spread of the disease process 
and the mortality to a sufficient extent to indicate 
its universal application. 



PROCTOLOGICAL EXAMINATION AS AN 
AID TO GENERAL DIAGNOSIS. 

By Arthur A. Landsman, M. D., 
New York, 

Associate Surgeon, Diseases of the Rectum, Post-Graduate Medical 
School and Hospital; Attending Rectal Surgeon, Jewish Memo- 
rial Hospital; Deputy Surgeon, Diseases of the Rectum, 
Out Patient Department, New York Hospital, etc. 

The full objective of a local examination is not 
attained by the determination of abnormality or 
disease in a suspected organ or area, or its exclu- 
sion therefrom; if such an examination is to fulfill 
its best purpose, it must not end with the local 
findings, but should, if possible, serve as an addi- 
tional means of investigation of the disturbance, no 
matter where located. That certain general con- 
ditions produce definite and characteristic changes 
in remote organs not primarily concerned in the 
disease must be admitted. The well trained oph- 
thalmologist may readily detect the presence of 
some general conditions by an examination of the 
eyegrounds : indeed, he may thus be able to throw 
some light on the nature of the disturbance and even 
estimate its prognostic importance. 

While this may not apply in a like measure to 
all organs, it would seem reasonable to suppose that 
a profound systemic disturbance would leave im- 
pressions upon an essential organ which may be 
interpreted in terms of diagnosis because of their 
frequent association with definite pathological lesions 
elsewhere in the body. It is our firm belief that 
the science of proctology may at times be so utilized 
as an aid to diagnosis of general diseases, obscure 
and otherwise, by the discovery of changes in and 
about the anorectal parts, which may be regarded 
in some cases as pathognomonic of particular dis- 
eases, in others at least strongly presumptive of 
their presence. 

The first of these which suggests itself in this 
connection is syphilis, which has superior claims 
because of its importance as a social problern en- 
tirely aside from what- we know of its ill effects 
upon the health and well being of the httman race. 
It is particularly true of ihis disease that early diag- 
nosis is the means of preventing potential injury, 
in proportion as its delayed recognition spells 
disaster. Hence anything which may aid us in 
discovering its presence as early as possible must 
be a welcome addition to our defensive forces ; and 
it is an indisputable fact that careful proctological 
examination has more than once resulted in un- 
covering evidence from which a tentative diagnosis 
of syphilis has been made and confirmed later by 
the development of unmistakable symptoms. 

The primary lesion of syphilis is very rare in- 
deed about the anus and rectum, but when it does 
occur it is well to remember that it may fail to 
show its usual characters because of the physical 
conditions which exist in this region, having a ten- 
dency to modify and blur the classical picture (1) 
as the proctologist sees it. The anorectal chancre 
may take the form of multiple fissures or ulcers 
between the radial folds, with hypertrophy of the 
skin, maceration of the superficial epithelium, offen- 
sive discharge, and a swelling of the inguinal lymph 
glands. Simple nonspecific anal fissure does not 



January 8, 1921.] LA.WDSMAN: DIAGXOSTIC VALUE OF PROCTOLOGIC AL EXAMINATIONS. 



61 



generally exhibit these symptoms, hence in their 
presence the possibility of lues must be given seri- 
ous consideration, even in the absence of clinical 
signs which are known to occur in genital chancre. 

We had the opportunity of seeing one such case 
in a married woman who presented herself for treat- 
ment in our clinic for acutely painful radial ulcers 
at the anal margin, for which she had received pro- 
longed medical treatment without any marked suc- 
cess. Although they possessed the characteristics 
described above, which should have directed our 
attention to the true nature of the trouble at once, 
it remained unrecognized until some weeks later, 
when successive confirmatory symptoms made the 
diagnosis clear aiid led to admissions by the patient 
which disclosed the mode of the infection. 

Oval patches of macerated skin on the opposing 
surfaces of the buttocks, close to the anus, may 
occur as anorectal symptoms very early in the dis- 
ease, sometimes the only gross evidence of it. They 
are the socalled broad based condylomata, generally 
regarded pathognomonic of lues, and so distinctive 
in appearance that, once seen, their significance will 
not be easily overlooked. They are, however, not 
the only type of condylomata found about the ano- 
rectal region ; the acuminate variety, which are ex- 
crescences of the skin — histologically, pure papillo- 
mata — occur with relative frequently, but have been 
generally lield to be nonspecific. In an admirable 
."^tudy by Creadick, of Yale (2), ten out of twenty 
gave a strongly positive Wassermann reaction, 
and we may yet have to revise our opinion con- 
cerning their etiology. 

The deposit of plastic material in the rectum which 
results in the thickening of the wall and narrowing 
of the lumen, produces characters which, if not spe- 
cific, are strongly suggestive of syphilis. Strictures 
of luetic origin are firm, smooth, and inelastic, with 
a tendency to become annular and to infiltrate the 
gut to a considerable extent. They form a large 
percentage of all strictures of the colored race. 

Occasionally the presence of nonspecific anorectal 
disease may indirectly lead to the discovery of lues 
in a person who never presented any evidence of it, 
as it did in one of our cases. The patient, a married 
woman with a negative history (3), came into the 
hospital for treatment of a chronic purulent rectal 
discharge which was found to be caused by a blind 
internal fistula. An operation was advised and 
attempted under local anesthesia. The manipula- 
tions disclosed a striking diminution of the pain 
sense in the tissues about the anus, below the lower 
half of the sacrum, to such an extent that they could 
be cut without the use of any anesthetic. A neuro- 
logical examination disclosed changes in the deep 
reflexes and pupillary phenomena which resulted in 
the establishment of a diagnosis of incipient tabes, 
based upon an old syphilitic infection. 

In another case, the patient, a woman, was sent 
to the hospital on account of recurrent attacks of 
severe bleeding of the rectum, complicated by loss 
of control of the bowel. The anal canal and rectum 
were relaxed to such an extent that they could 
easily be held open and inspected without the use 
of any instrument, and offered no resistance to the 
introduction of the finger. The skin surrounding 



the anus was moist and eczematous, the hair absent, 
the anal opening deep, sunken, fissured and funnel 
shaped, the mucous membrane ulcerated and bleed- 
ing. A diagnosis of ulcerative proctocolitis was 
made secondary to pederasty, which was indignantly 
denied by the patient. However, her .family 
physician gave the information later that she 
admitted unnatural coitus in an effort to prevent 
pregnancy (4). 

But syphilis is not the only disease which pro- 
duces recognized changes about the anorectal region ; 
in tuberculosis we have another which is responsible 
for more or less characteristic symptoms in the 
form of lesions which may be identified as a part 
of the .specific process. In most instances tuber- 
culosis is not primary about the anus and rectum, 
but appears as a secondary infection from a focus 
elsewhere in the body. IBut whether primary or 
secondary, soon enough it assumes clinical appear- 
ances which leave little doubt to the experienced 
eye as to its true character. Of the lesions which 
are best marked, ulceration about the perianal tis- 
sues, anal canal and rectum, and fistula in ano 
stand out prominently and present distinguishing 
features clearcut and impressive. Ulcerations about 
the anus may either begin in the skin around it or 
follow by direct extension of the process from the 
lower portion of the anal canal, especially in persons 
with pulmonary tuberculosis, active or latent. They 
present to the naked eye shallow, irregular, uneven 
lesions with a wormeaten base and thin undermined 
edges, a description which applies equally to ulcers 
of the mucous membrane, where, however, the ques- 
tion of dilTerential diagnosis between tuberculosis 
and malignancy is often puzzling. In the latter con- 
dition the ulcers have a tendency to become deep 
and craterlike, with raised edges and hard borders, 
imparting to the palpating finger the sensation of 
a firm, hard infiltration, altogether absent in lesions 
of tuberculous origin. Tuberculous fistula follows 
abscess about the anorectal region, which is caused 
by the tubercle bacillus or invaded by it secondarily. 

When it occurs in persons who present obvious 
signs of pulmonary tuberculosis, the diagnosis sug- 
gests itself readily enough and errors will be 
avoided ; but in a certain number of cases the fistula 
is the first and, for a time perhaps, the only mani- 
festation of the constitutional infection, in an indi- 
vidual who may present no frank signs of ill health. 
A tuberculous fistula, while it may for a time show 
no local signs of its true character, will sooner or 
later develop marks which will serve to distinguish 
it from the nonspecific variety (5). The external 
opening is relatively large, its mouth gaping and 
ragged, its borders bluish and undermined in every 
direction, and the surrounding skin presents every 
evidence of poor nutrition. Moreover, the parts 
soon begin to show the wasting incident to such a 
grave systemic infection : the buttocks lose their 
rounded contour and become flattened, the bony 
landmarks prominent, the anal cleft deep and 
sunken, the hair silky and long, the skin dry and 
scaly — changes which should at once arouse a strong 
suspicion that the fistula may be merely the local 
manifestation of a constitutional disease. 

Any prolonged resistance to the free return of 



62 



MEDICAL SOCIAL SERVICE. 



[New York 
Medical Journal. 



blood into the liver, whether from within or with- 
out, will in time cause dilatation in the course of 
the vessels as a compensatory process, despite the 
fact that under these circumstances a greater pro- 
portion of the blood from the rectal veins must 
be returned to the general circulation by way of 
the vena cava ; hence it is quite clear that a diagnosis 
of hemorrhoids is incomplete without an attempt 
to establish the underlying cause. This must sug- 
gest itself in such diseases as tumors and infections 
about the pelvis, malpositions and new growths of 
the uterus and adnexa, pathological processes any- 
where in the course of the vessels which interfere 
with the circulation, or diseases of the liver, such 
as hepatic cirrhosis, which obstruct the free flow 
of blood through it. Carried a step further, any 
long continued disease of other organs which causes 
a congestion of the hepatic circuit will secondarily 
produce interference in the portal circulation and 
may result in symptomatic hemorrhoids. Hence 
their frequent association with chronic gastric, 
cardiac, and nephritic affections. 

In normal health the rectal sphincters are in a 
state of tonic contraction and the anal opening is 
closed, more perfectly in the young and vigorous 
than the aged and feeble, to the extent that the 
introduction of one finger is all they will bear with- 
out painful reaction. Operators who are especially 
skillful may be able in some subjects to stretch the 
sphincters under careful local anesthesia, but it is 
the general experience that to dilate them thoroughly 
the patient must be deeply narcotized. In persons 
who suffer from spinal and cerebral disorders, how- 
ever, which interfere with the innervation of the 
sphincters, there may be an abnormal relaxation of 
these structures which should at once call attention 
to a possible disturbance of nervous origin; the 
same may be said of fecal incontinence as a symp- 
tom when it is not due to local disease or to a post- 
operative complication. Such extreme degrees of 
relaxation may occur in tabes, general paralysis of 
the insane, multiple sclerosis, cerebrospinal syphilis, 
neoplasms or injury affecting certain portions of 
the central nervous system or spinal cord ; patients 
presenting these symptoms are likely to be brought 
to the proctologist in the behef that the trouble 
is due to rectal disease. Hence, he should be pre- 
pared to understand the pathology of these ctnidi- 
tions in order to classify them properly and refer 
them to those best able to treat them. 

Subjective sensations about the anorectal region 
are of interest in connection with the diagnosis of 
general diseases, but cannot be discussed in greater 
detail here. Enough has been said to show that 
because of the intimate relations of the various 
organs of the body, disease of one is likely to pro- 
duce physical changes which may be viseful in diag- 
nosis because of their frequent association with 
certain pathological states. 

RFFERENCES. 

1. Lynch : Diseases of the Rectum, p. 283. 

2. Creadick : Journal A. M. A., October 16, 1920. 

3. S. H. : Liecords of Rectal Clinic, New York Hos- 
pital, Dr. Pool's Service. 

4. N. P. : Records of Rectal Clinic, New York Hos- 
pital, Dr. Pool's Service. 

5. Hill and Lani)SM.\n-: Journal A. M. A., March 22, 
1919. 



MEDICAL SOCIAL SERVICE IN 
DISPENSARIES.* 

By the Public Health Committee of the New York 
Academy of Medicine. 

I. BRIEF HISTORICAL ACCOUNT. 

Medical social service, which began in this coun- 
try in Boston a decade and a half ago' to enhance 
the efficiency of hospital medical work and to ren- 
der, the results more enduring, has found its way 
into the -institutions throughout the continent and 
has become a recognized ancillary department in 
the dispensary as well as in the hospital. Its ac- 
tivities in the outpatient departments numerically 
exceed those in the hospitals. 

The growth of medical social service has been 
so rapid and spontaneous as to elude standardiza- 
tion. There exist differences in the fundamental 
conceptions of the functions of this new branch of 
hospital and dispensary organization and accord- 
ingly the methods of procedure and the technic 
differ materially. 

The existence of organized medical social service 
has been too short to provide for the training of 
workers on a scale commensurate with the impor- 
tance of the task and the tieeds of the service. 
Many of the hospitals give practical instruction in 
this branch of work to the pupils of the training 
schools. The first clearly defined and systematic 
courses of instruction were established by Simmons 
College in Boston and by the University of Indiana 
in connection with the Robert W. Long Hospital at 
Indianapolis. In Boston the course is given imder 
the auspices of the School for Social Workers main- 
tained by Simmons College and Harvard Univer- 
sity. It consists of class instruction and practice 
work in connection with the social service depart- 
ments of the Massachusetts General Hospital and 
the Boston Dispensary. In Indiana the instruction 
was originally given in the department of sociology 
but later was put in a department by itself. 

A course in medical social service is being offered 
at the University of California in conjunction with 
the department of social economics of the Univer- 
sity. The Chicago and Philadelphia Schools of 
Social Work, and the New York School of Social 
Work (formerly the School of Philanthropy) offer 
theoretical and practical instruction in medical social 
service, but all of it is still in the first stages of 
development, owing to the newness of the profes- 
sion and the lack of generally accepted standards. 
The Smith College Training School for Social 
Work has organized a course for medical social 
workers, following its successful war experiment 
in the training of social workers for psychiatric 
clinics. The course offered at Smith College con- 
sists of eight weeks of theoretical instruction, fol- 
lowed by a- period of nine months' practical train- 
ing at the hospitals with which arrangements have 

*This constitutes a part of the report on the Dispensary Situation 
in New York City by the Public Health Committee of the New 
York Academy of Medicine, of which Dr. Charles L. Dana is chair- 
man. Dr. James Alexander Miller is secretary, and E. H. Lewinski- 
Corwin, Ph. D., is executive secretary. 

' One of the earliest experiments in hospital social service in 
New York was in connection with the Children's Department of the 
Post-Graduate Hospital, under the direction of Dr. H. D. Chapin. 
It was started in the spring of 1890. 



January 8, 1^21.] 



MEDICAL SOCIAL SERllCE. 



1)3 



been made for the purpose, and a concluding sum- 
mer session of class study. In the first eight weeks 
the students "are made acquainted with the applica- 
tion of the scientific method in sciences bearing 
upon social problems," and receive instruction in 
the etiology and the preventive aspect of certain 
diseases. The concluding period of advanced in- 
struction is designed to correlate the acquired field 
experience of the student with scientific research 
through class conferences, discussions and lectures. 
The department of nursing and health at Teachers' 
College, Columbia University, is likewise develop- 
ing a course of instruction for third, year students 
of approved training schools, as well as for graduate 
nurses. There "are probably other schools which 
ofifer similar instruction. 

The American Association of Hospital Social 
Workers, as well as local associations, present 
forums for the discussion of the various problems 
encountered in the discharge of the manifold duties 
devolving upon them. The Hospital Social Service 
Association of New York City holds stated meet- 
ings, publishes a quarterly and a bulletin and oft'ers 
a course of lectures to nurses interested in social 
work. Training of medical social service workers 
for certain types of cases, such as the tuberculous 
and mental, has been carried on by several organiza- 
tions. 

II. SCOPE AND FUNCTIONS. 

The bulletin of the department of social service of 
Indiana University descrebes medical social work 
as "a part of the wider public health movement and 
the present demand for efficiency, even in medicine." 
It goes on to say that a social service department 
fails or succeeds precisely in so far as it is able : 

1. To procure for each individual patient whatever the 
medical institution needs for him, but should not itself pro- 
vide, in order to complete his care or cure. 

2. To educate each patient and student with whom it 
comes in contact. He should understand the interrelations 
of vice, poverty, and disease; of physical, mental, and eco- 
nomic conditions. 

3. To follow each patient until he is as thoroughly re- 
established as possible and to carry to his community, through 
the patient or otherwise, added knowledge of bad physical 
conditions — and a way in which to eliminate or prevent 
them — which increase man's burden and make for human 
misery. 

The formulation of the scope and functions of 
medical social service, as far as it has been at- 
tempted, emphasizes the importance of considering 
the environmental background of the patient in 
securing the best results from medical treatment. 
Davis and Warner ( 1 ) briefly define medical social 
service work as meaning "assistance to the physi- 
cians in the education of patients and the control 
of their environment." Miss Ida Cannon (2) de- 
scribes it as an ef¥ort "to understand and to treat 
the social complications of disease by establishing 
a close relationship between the medical care of 
patients in hospitals and dispensaries and those 
skilled in the profession of social work." 

For purposes of ascertaining the organization 
and methods employed in the medical social service 
departments in New York city, a survey was made 
of these departments with special reference to the 
dispensaries. An agent of the Public Health Com- 
mittee, herself a medical social worker, interviewed 



the person in charge of each department and also 
copied a number of records from the files of each 
department. 

Among the questions asked of the head of each 
social service dei)artment studied, was one relating 
to the function of the department as conceived by 
the institution. The following is a summary of the 
replies regarding the function of social service, 1, 
with reference to the clinic physicians, and, 2, With 
reference to the patients and the community. 

1. As far as the relation of the social service 
department to the physicians was concemetl. 
"informing the doctors as to the social needs of the 
patients and of the assistance available throu'gh the 
social service department," was the definition given 
by six institutions. In four of the institutions the 
function was regarded as consisting of "reporting to 
the doctor the social conditions bearing on patients' 
illness." "Helping the doctor to complete treat- 
ment of patients" was the answer given by one of 
the chief workers. In three of the institutions the 
duty was conceived to be that of assisting doctors 
in carrying out treatment of patients; in three 
others, "interpreting doctors' instructions to pa- 
tients." Another formulated it as consisting of 
"assisting physicians in explaining advice to pa- 
tients" ; and still another as "assisting physicians in 
giving patients a new favorable start in the com- 
munity." 

2. Regarding the responsibility of the social 
service department to the patient, fifteen institu- 
tions defined it as "establishing the patient or the 
family as an independent economic unit in the com- 
munity" ; seven as "education of the patient and 
family in hygiene," one, as affording "physical, 
mental and moral regeneration of the family" ; 
one as "assisting patient in regaining health" ; one 
as "educating the patient in the resources of the 
community, which 'can be used in solving his diffi- 
culties" ; one as "aiding the patient in readjustment 
after illn.ess" ; one as "advice and assistance to the 
family." One department dealing with mental 
cases only, defined its work as "education of the 
patient and the public in mental hygiene"; another 
specialized service, one dealing with children, limits 
its function "to the remedying of family difficulties 
to insure more efficient care of the child and prevent 
future illness." In the judgment of one depart- 
ment, "social .service work means special treatment 
when necessary" ; another limits its field of work 
to the "education of the patient as to the need of 
treatment"; two others, to "securing hospital treat- 
ment for the patients"; ajd still another to the 
"bringing of outside resources to co-operate with 
the hospital in the treatment of the patient." 

From this sivmmary it will be seen that the field 
of endeavor to which medical social service has ad- 
dressed itself is very broad and varied. In 1913 
Miss Cannon wrote as being impressed "by the di- 
versities in the interpretations of the hospital social 
worker's function, and by the great need for more 
adequately trained workers" (3). A report of the 
committee on training made recently (June 5, 1919) 
at the annual meeting of the Ainerican Association 
of Hospital Social Workers likewise revealed the 
existing broadness of conception of the scope of 



64 



MEDICAL SOCIAL SERJICE. 



[Xew York 
Medical Journal. 



the work and the lack of standard methods of 
procedure. 

A study of the records of the several social 
service departments in the dispensaries of New 
York throws a great deal of light upon the methods 
pursued in social service work. As has heen stated 
above, six institutions recognize the education of 
the doctor to the social needs of the patient, as one 
of their functions. Assuming this to be one of the 
duties of the social service department, the two 
functions involved in carrying it out are : gaining 
the information and imparting it to the doctors. 
In the tuberculosis clinics and in the cardiac clinics 
the information as to the social facts is kept with 
the medical findings and is readily available to the 
physician. In all the other departments, with few 
exceptions, there are no systematic methods of con- 
veying to the physician the information about the 
social environment of the patient. The worker may 
• or may not remember to supply the doctor with the 
information ; at times he has to call for the desired 
data. The records of the social service department 
are not filed with the medical histories and there- 
fore do not become automatically available to the 
physician at the time when the patients present 
themselves for further attention. 

Three fourths of the institutions studied felt that 
their greatest obligation to the patient was to refit 
him for his place in the community. Yet among 
the patients under care in the various social service 
departments which came within the compass of our 
study, this was the evident problem in only a small 
percentage of cases. Seven head workers empha- 
sized the importance of educating the patients and 
families in hygiene ; among the cases studied about 
one third were accorded this service. 

The lack of precise formulation of the function 
of medical social service has resulted in the use of 
the department for all kinds of work belonging to 
other branches of the institutional organization, 
and has overburdened the social service depart- 
ments with work which might or should be handled 
through other agencies. As the medical social 
workers are usually nurses, they are frequently 
called upon to help the physicians in the clinics by 
taking temperatures, weight and cultures, to the 
detriment of their special work. As a broad propo- 
sition, it may be stated that the requests of the 
physicians and the managers determine the func- 
tions of the department to a very large extent. The 
analysis of the table of Functions Performed, 
found in another part of this report, bears out 
this statement more fijlly. 

III. THE PERSONNEL OF THE SOCIAL SERVICE DE- 
PARTMENTS AND THE EXTENT OF THEIR 
WORK IN THE DISPENSARIES. 

Practically all the institutions in New York whicli 
were known to maintain social service work were 
visited by the special agent of the Public Health 
Committee. Of the institutions studied, twenty- 
one had definitely organized departments, while in 
four the work was organized on a basis different 
from that of the ordinary social service department. 

The twenty-one institutions in which the social 
service could be studied for purposes of comparison 
are as follows : 



DISPENSARIES CONNECTED WITH GENER.AL HOSPIT.\LS. 

Bellevue St. Luke's 

Mount Sinai Beth Israel 

Post-Graduate Brooklyn Hospital 

Roosevelt Lincoln 

Long Island College New York Hospital 

French Presbyterian 

INDEPENDENT DISPENSARIES. 

Vanderbilt (College) New York Dispensary 

Cornell (College) Brooklyn City Dispensary 

University and Bellevue (College) 

DISPENSARIES CONNECTED WITH SPECIAL HOSPITALS. 

Woman's Hospital Ruptured and Crippled 

N. Y. Eye and Ear Infirm- Skin and Cancer 
ary 

Seventeen institutions have more than one 
worker. In many of the institutions there is no 
dififerentiation of function and the social service 
workers do the hospital as well as the dispensary 
work. Some of tfie institutions employ a consid- 
erable number of workers. In one hospital, for 
instance, there is a head worker with twenty-four 
assistants. One has a head worker and twelve 
assistants ; two have seven assistants each ; two 
have six assistants (in one of these, two of 
the assistants are graduate nurses assigned to hos- 
pital follow-up, and two are senior pupil nurses 
assisting in the home nursing, but directed by head 
workers) ; two have five assistants each; eight have 
two assistants each ; and four have one assistant 
each, making a total of 102 paid social workers. 
In addition, eight institutions have paid clerical 
helpers, two of them employed by one institution, 
which also has a bookkeeper, a messenger and a 
telephone operator in the social service department. 

Very few volunteers are used in connection with 
the social service work. Fifteen institutions do not 
use volunteers at all ; six use them only for clerical 
help ; and in only one institution are volunteers used 
in connection with the visiting of patients. The 
reason for this lies probably in the exactitude of 
the work and the importance of continuous service 
for efficiency. It is very seldom that volunteers can 
be counted upon to give intensive application to the 
work. In all the institutions the head workers com- 
plained of the shortage of capable assistants, and 
in seven institutions complaint was made about the 
inadequate office space allotted to the work. 

Fifty-seven of the assistants in social service 
work, or about sixty-two per cent., devote their 
time to the dispensaries. Of the seventeen chiefs of 
the social service departments, fourteen divide their 
time between the dispensaries and the hospitals, 
and three give all their time to the dispensaries. 
This large number of workers in dispensaries, as 
contrasted with the number doing hospital social 
work, shows the tendency away from the original 
limitation of social service to ward patients only, 
although in most of the institutions the main seat 
of the social service is still in the hospital. In only 
one of the general hospitals is the social service 
office located in the dispensary and doing most of 
its work for dispensary patients, aUhough it assists 
with indoor cases as well whenever they are re- 
ferred from the wards. In some institutions, how- 
ever, particularly the special hospitals, the hospital 
social service is regarded as of greater importance 
than the dispensary social service. 



January 8, 1921.] 



MEDICAL SOCIAL SERVICE. 



65 



IV. RESOURCES AND AUXILIARIES: AND ASSIGNMENT 
^ OF STAFF AND ITS RESPONSIBILITIES. 

Funds for social- service are usually raised by 
women's auxiliaries which, either independently or 
jointly with the institutional authorities, exercise 
control over the social service. In seventeen insti- 
tutions out of the twenty-one included in this sur- 
vey, the funds were raised in this manner; only- 
four of these auxiliaries include any representation 
of the hospital board. In one hospital, the depart- 
ment was maintained by tlie New York School of 
Social Work, in another the Mental Hygiene Com- 
mittee of the State" Charities Aid Association main- 
tains social service for a certain type of patients ; 
and in two institutions a special fund, donated by 
private individuals, is put at the disposal, in one 
case of the superintendent of the hospital, and in 
the other of the director of nurses, who have sole 
authority over the social service departments. The 
total amount of money spent on social service work 
has not been ascertained, neither has the prevailing 
rate of salaries paid to the workers. In many insti- 
tutions the staff is insufficient to meet the needs 
(this was particularly so during the war) but only 
in one case, was a definite complaint made of lack 
of funds. 

Because of the independence of the funds for 
social service, the medical social service staff, un- 
like other paid workers in the hospitals, is account- 
able not to the superintendent of the institution, 
but either to the auxiliary only or to a composite 
body representing the auxiliary and the hospital 
authorities. In six instances their responsibility 
is entirely to the auxiliary composed of interested 
women who have no connection with the hospital 
management. In three instances the hospital or 
dispensary board is represented on the auxiliary. 
In one instance the supervising authority consists 
of the auxiliary, the superintendent of the hospital, 
the supervisor of nurses, and a representative of 
the board of managers, hi three instances the so- 
cial service is managed by the women's auxiliary 
and the superintendent; in one instance, the women's 
auxiliary and the supervisor of nurses ; in one in- 
stance, the women's auxiliary and the Association 
for Improving the Condition of the Poor ; and in 
four other instances, mentioned before, they are 
responsible to the Mental Hygiene Committee of the 
State Charities Aid Association, the School of Social 
Work, the superintendent of the hospital, and the 
director of nurses, respectively. 

With the exception of one instance where con- 
siderable friction was reported to exist between the 
social worker who was responsible to the auxiliary 
and the supervisor of nurses, the inquiry did not 
bring out the existence of any tension or adminis- 
trative difficulty due to the division of responsibility 
or the independence of the social service depart- 
ment from the rest of the hospital organization. 
The responsibility of the medical social service de- 
partment to a group of interested, nonprofessional 
women is of advantage in that it keeps the human 
elements of the problem fresh and vivid and brings 
to the aid of the work wider social and financial 
resources, but it is faulty from the viewpoint of 



administrative organization and is likely to retard 
the recognition of social service as an indispensable 
integral part of dispensary and hospital work, am- 
ple provision for which should be made in the gen- 
eral budget of each institution. 

V. THE TRAINING OF MEDICAL SOCIAL WORKERS 
AND THE REQUIREMENTS. 

In only three of the New York institutions 
studied are opportunities offered for the sy.stematic 
training of women for medical social service. One 
is the Post-Graduate Medical School and Hospital, 
where the social service department is a branch of 
the New York School of Social Work and where 
regular instruction is given : and the others are the 
Neurological Institute Dispensary and the Clinic 
for Mental Diseases at Cornell, where courses are 
given to such students of the Smith College Train- 
ing School for Social Work as specialize in mental 
hygiene. In no other institutions are any oppor- 
tunities for training provided, except that the pupil 
nurses of the respective training schools get a cer- 
tain amount of experience ifi medical social work 
under the guidance of the department. In four 
institutions this experience of pupil nurses does not 
exceed two weeks, one month, two months, and 
three months, respectively. In three institutions 
the opportunity is afforded to one nurse at a time — 
in one institution for one month, in the second for 
two months, and in the third for three months. In 
the institution where the three months' training is 
given it has been only for senior class nurses. In 
two institutions only probationers are instructed 
for a few weeks; in another, the pupil nurses are 
required to make visits with the medical social 
workers for a certain period of time. In the Pres- 
byterian Hospital the senior nurses spend four 
months with the Henry Street Settlement workers 
in addition to two months in the social service de- 
partment of the hospital. This constitutes the 
whole field of instruction available in the hospitals 
for either nurses or others desiring training in 
medical social service work. 

At every institution studied an effort was made 
to obtain from the chief of the social service de- 
partment a description of the essentials of educa- 
tion and other qualifications for a successful med- 
ical social service worker. A perusal of the an- 
swers shows that there is an insistence on the need 
of preliminary nursing education, and a lack of 
sufficient appreciation of a thorough grounding in 
social economy and social "case work." 

The prevailing idea among the medical social 
workers of New York is that nursing education is 
an essential prerequisite for the successful perform- 
ance of the work. It must, of course, be admitted 
that a great deal of the knowledge which a nurse 
possesses is of service in dealing with hospital cases 
and in connection with the visiting of certain types 
of cases, particularly where instruction to the pa- 
tient as to how to follow the doctor's advice in 
treatment is part of the problem. The fact of her 
being a nurse makes her message more authorita- 
tive. It is undoubtedly true, also, that a woman 
with initiative and imagination and a sympathetic 
interest in her work, possessing training in social 



66 



MEDICAL SOCIAL SERVICE. 



[New York 
Medical Journal. 



technulotiy, is fortified in performing her functions 
when she has had nursing education too. There are 
such women in the field of social work now, but 
it would "be inadvisable to limit the field of med- 
ical social service to nurses exclusively. Our study 
of the social service departments in New York has 
shown that the Post-Graduate Hospital, where the 
work is done by students of the School of Social 
Work imder the guidance of a director who has 
had no nursing training, compares very favorably 
with other institutions where none but nurse work- 
ers are employed. In the Massachusetts General 
Hospital, of the thirty-two workers only three are 
nurses. Miss Cannon, the chief of that service, 
herself a nurse, states that it is difficult to obtain 
women who, in addition to their nursing education, 
possess a thorough social training and are prepared 
to work as social workers, and not primarily as 
nurses. In Washington University Hospital 
(Barnes Hospital), at St. Louis, the University of 
Pennsylvania Hospital, at Philadelphia, and the 
General Hospital of Cincinnati, excellent social ser- 
vice work is carriec^ on under the guidance of 
women with no nursing education. Likewise, in 
the Robert W. Long Hospital at Indianapolis, which 
is part of the Medical School of the University of 
Indiana, the .social work is done entirely by students 
of the medical, nursing and sociological schools. 
The instruction and direction is given by women of 
no nursing experience. The character of the work 
done is of a high grade. Many of the students in 
the university utilize their experience in social ser- 
vice work as a basis for masters' and doctors' 
theses. It would therefore seem most inadvisable 
to exclude from the new profession by a rule of 
thumb the large numbers of women who, by editca- 
tion other than nursing, would be qualified to carry 
on the work satisfactorily. 

Furthermore, the training of nurses, as it has 
been carried on, and still is to a large extent, is not 
designed to nurture qualities of mind indispensable 
to successful social work of a high order. The 
nature of a nurse's work as ordinarily understood 
does not call for much initiative and independent 
judgment ; on the contrary, she must learn how to 
carry out instnictions. There are certain inhibi- 
tions which must become a part of her professional 
consciousness and behavior if she is to prove suc- 
cessful in her bedside work. 

Under the circumstances it was only from among 
the nurses who have had a broad prenursing edu- 
cation and who are possessed with a quick intelli- 
gence and a inind above the average that medical 
social service workers have been recruited in New 
York. It is due to these superior qualities, and not 
to their nursing education, that they have been able 
to render services of a high grade. The hospitals 
of New York, with the exception of two, have never 
tried to enlist the services of others than nurses 
for the work. 

As they are constituted at present, neither the 
training schools for nurses nor the schools for 
social case workers are of¥ering adequate prepara- 
tion for medical social workers. There is obviously 
a need of a new type of training which would 
qualify women for this new and growing profes- 



sion. By the nature of things it must be built on 
two foundation stones : one is a broad appreci^ion 
of the etiology of disease and an intelligent under- 
standing of certain medical procedures ; and the 
second is a knowledge of social conditions and the 
technology of family case work. 

VI. RECORD FORMS. 

As in the medical part of the study the character 
of the work was judged by the information gleaned 
from the records, so in the social service study an 
analysis of the records was made with a view of 
determining how the social service departments 
work, and what they accomplish. As in the case of 
the dispensary physicians, it is no doubt true that 
the social workers do more than their records indi- 
cate, but an objective study of the work must be 
made on the basis of what the worker considers 
worth recording for his or her guidance or for the 
permanent handling of the case. Before consider- 
ing the results of this analysis of case records, it 
will be well to consider the record forms now used. 

The employment of uniform record forms would 
be advantageous, even if it is .not necessary to 
record for every patient all of the information 
called for thereon, as such uniform records would 
facilitate the functioning of a central clearing bu- 
reau, and also would make possible studies aimed 
at the crystallization of social service function and 
procedure. At the present time there exists a great 
diversity in forms used. They differ in the amount 
of information called for, in the arrangement of 
items, as well as in the size of the forms themselves. 
The number of headings on the record^ ranged 
from sixty-five to twenty-seven. There are only 
nine headings which appear on all the forms from 
the fourteen institutions whose blanks have been 
analyzed. Those nine headings are : name of pa- 
tient, address, age of patient, addresses of friends 
and relatives, years in the United States, diagnosis, 
present occupation, marital status and earnings. 
With regard to the earnings, on three records there 
is no statement qualifying the income, as weekly 
or monthly. On twelve records the weekly income 
is inquired into, but in only five instances was it 
made clear whether it was the income of the last 
week or of an average week. On some records pro- 
vision is made for the ascertainment of both the 
"present wage per week" and "the normal wage 
per week." Some of the records call for just the 
wages, o'thers for incomes from all sources. It goes 
without saying that a uniform and precise procedure 
with regard to so iinportant an item as the financial 
resources of the family is essential. On all of the 
records except one, information is asked concern- 
ing the church affiliation of the patient-. 

Without going into detailed computations on how 
many of the blanks the several items of information 
are found, it may be said that the records diflfer 
considerably from each other, but as a rule ample 
provision is made for obtaining essential facts. 
The facts sought can be broadly divided under six 
heads: 1. Information needed for the identification 
of the patient, which includes data concerning the 
patient's name, address, age, sex, nationality, time 
in the United States, conjugal status, etc. 2. Med- 



January 8, 1921.] 



MEDICAL SOCIAL SERVICE. 



67 



ical history, i. e., past and present histor\-, the diag- 
nosis, treatment and complications of condition. 3. 
The training and work of the patient, which covers 
education, special fitness, past and present occupa- 
tion and the nature of work. 4. Home and family 
— This calls for information concerning the size of 
the family, the number of dependents, -number of 
rooms occupied, ventilation, and other sanitary fea- 
tures of the dwelling. 5. The financial .status — by 
which is meant information concerning the wages 
and other sources of income, also data bearing on 
the budget of the family, particularly such items 
as rent, insurance, and other definite ascertainable 
expenses. 6. The social service problem and what 
has been done for the patient. 

The information concerning all these points is 
inquired into by the several institutions with a vary- 
ing degree of fullne-ss. The greatest similarity of 
questions pertains to the identification information. 
The items concerning the medical history show a 
minor degree of likeness. Every record, however, 
has space for diagnosis. On some of the blanks 
there is an entry for previous treatment or for 
previous places of treatment, and on two, for pre- 
vious illness. Likewise on only two of the cards 
is space provided for present medical treatment and 
on three for complications. It would seem that the 
records call for too little information concerning 
the physical and mental condition of the patient, 
the mode of treatment prescribed and progress 
made under treatment. 

With regard to the training and work of the 
patients, the present or last occupation is invariably 
inquired into. Only one of the cards suggests an 
inquiry into the process of work and only three ask 
about the industry in which the patient has been 
employed. In five institutions the question is asked 
whether the employment is seasonal or steady. The 
question of unemployment is raised on nine of the 
record forms. In only one instance are the hours 
of work inquired into. Something regarding the 
education of the patient is required to be recorded 
in three institutions and in two his vocation and 
special training. Here, again, one might criticize 
the forms in that they do not provide for an ade- 
quate elicitation of information concerning the in- 
dustrial hazards of occupations and evidently do not 
lay particular stress upon the relation between 
disease and thp work and habits of patients. 

With respect to the home and family conditions, 
the information required is full and more or less 
uniform. Here again little importance is evidently 
attached to the obtaining of facts concerning the 
condition of health of members of the family other 
than the patient. Such information would be of 
importance from the point of view of making plans 
for the family as well as from the standpoint of 
disease prevention. 

With reference to the financial conditions of the 
patients, the questions about the income have been 
discussed above. On the whole, the schedules on 
that score are satisfactory, although in only few 
instances are inquiries made into the family budgets, 
except as to expenses for rent. 

As to the social service problem, in five instances 
the arrangement of the record calls for a definite 



statement of the social diagnosis or tlie immediate 
need or the apijarent underlying prol)lcni. In all 
other instances no statement of the [jroblem is at-' 
tempted. The same five record blanks, with per- 
haps one exception, call for rather minute informa- 
tion concerning the social worker's efi'ort in the 
case and the final disposition of it. The other cards 
vary in detail with regard to these points : some 
provide for the discussion of items of relief and 
other services performed. The records can be im- 
proved in this respect also. 

On the whole it may be said that the social ser- 
vice record forms, as they are, call for a great deal 
of relevant information. In most instances the data 
secured are probably sufficient to permit a proper 
planning of action. What most of the records need 
very badly is a topical arrangement of information 
under several general headings and the segregation 
of data in such a way that the details of the investi- 
gation would be separated from the main facts 
about the physical condition of the patient and his 
economic and social difficulties. Above all there is 
a need of a similarity of recording of the facts and 
also of assigning precise meanings to the terms 
used. 

VIl. STUDY OF THE CONTENT OF SOCIAL SERVICE 
RECORDS. 

An analysis was made of 675 records selected at 
random from the files of the institutions studied. 
Of the records examined 301, or 44.5 per cent., 
were children's cases; 121 concerned men, and the 
remaining 248, women. These records gave detailed 
information of the types of cases which receive the 
attention of the social service departments and of 
the methods of work employed, as well as the re- 
sults achieved. Tabulation of the records shows 
that on 88 .per cent, of them medical findings are 
indicated. It is admittedly of prime importance 
that the medical condition of the patient should be' 
stated in every instance of medical social service 
work. Likewise, in making plans for patients it is 
of importance to know and record what medical 
treatment has been indicated, and if no medical 
treatment is necessary, this fact should be recorded ; 
and yet only 59.3 per cent, of the records contain 
any reference to medical treatment. In 27.5 per 
cent of cases the family history of the patients is 
recorded and in only 20.3 per cent, of the cases is 
the patient's medical history given. 

Of the 675 patients whose records were ob- 
tained, 77.5 per cent, were visited in their homes. 
In the majority of institutions over 90 per cent, 
of the patients were visited. In some institutions 
all cases referred to the social service department 
are visited. Some, however, show a relatively 
small percentage of home visits- and this accounts 
for the average of only 77.5 per cent, of the cases 
visited. Among those which are considerably be- 
low the average in visiting are some of the best 
general out. patient departments, an excellent clinic 
for special cases and two university clinics. Al- 
though the total number of home visits recorded 
equals 77.5 per cent, of the cases, the general de- 
scription of the home conditions is given on only 
50.7 per cent, of the records, while 68.6 per cent. 



68 



MEDICAL SOCIAL SERF ICE. 



[New York 
Medical Journal. 



of the records indicate the number of rooms occu- 
pied by the families visited. 

The sources of income of the family are recorded 
in 71 per cent, of the total number of cases, and 
the family expenses are given in 69 per cent, of the 
cases. In the majority of instances, however, only 
several items of family budget are ascertained, 
chiefly rent. 

The present occupation of the patients is indi- 
cated in 61.5 per cent, of the cases, and the past 
occupation in 55.5 per cent. This poor showing 
with regard to a vital point of information cannot 
be explained by the fact that 44.5 per cent, of the 
cases were children and 36.7 per cent, women, be- 
cause in ever>- instance of a child the occupation 
was regarded as stated ; likewise, in cases of women, 
when the term housekeeper was given the occupa- 
tion was considered to have been recorded. 

In addition to the visits to the homes of the pa- 
tients, the social workers called on other persons 
or agencies which might be interested in the case, 
such as relief agencies, churches, employers, rela- 
tives, etc., and the records show that in 17.2 per 
cent, of the cases such additional visits were made 
by the workers. Besides these visits, other agencies 
were communicated with by letter or telephone, so 
that in all, cooperation was souglit in about 39 per 
cent, of the cases. 

It was on the basis of the medical data as to con- 
dition and treatment and on the information elicited 
by visits to and talks with patients, families and 
others interested that the social service problems 
were ascertained and plans laid to meet these prob- 
lems. In 96.5 per cent, of the cases the social ser- 
vice problem is indicated on the records", and in 
93.6 per cent, of the cases the solution of the prob- 
lem is formulated. 

Of the 675 cases- selected at randqm only 20.6 
per cent, were recorded as closed, and of these only 
three fourths bore the date of the closing. Some 
of the open cases were of long standing and no 
active work was being done with them. The study 
of the records indicates that nov/here has an at- 
tempt been made to ascertain the end results of the 
work and therefore it is impossible to judge in 
many instances what have been the achievements 
of the social departments. 

An effort was made to determine the causes for 
closing cases or the reason for keeping them open. 
In ninety cases, or 13.3 per cent, of the total, we 
could not determine whether the cases were open 
or closed. Of the 20.6 per cent, closed, in 9.8 per 
cent, the object had been accomplished. A small 
percentage was closed for each of the following- 
reasons : other organizations were interested ; the 
patient died or was lost in moving to another dis- 
trict or giving a wrong address ; some were referred 
to other doctors or institutions better fitted to treat 
the patients ; and in ten cases investigation showed 
no need for care. Three of the five cases classed 
as other reasons are significant in that they were 
closed because of a shortage of workers. The cases 
were from a teaching institution where the policy 
is, apparently, that no more work should be at- 
tempted than can be properly carried out. 

Among the 446 cases known to be pending, no 



reason for keeping the cases open could be ascer- 
tained for eighty-four patients; 322 needed further 
medical care or home instruction ; twenty-three cases 
needed further financial aid ; several of these cases 
were held open to repay a loan made for apparatus 
or special treatment. Opposition of the family 
made it necessary to keep three cases open, while 
among the cases closed, one was found where the 
reason for closing was uncooperative patient. 

According to the records only 40.5 per cent, of 
the cases were registered with the social service 
exchange of the Charity Organization Society. 
Some institutions make a large use of this agency, 
recording every case. One institution obtains infor- 
mation from the social service exchange, but regis- 
ters no cases with them, the reason being that the 
relation of the patient to the medical institution 
should be confidential and no names of patients 
should be divulged to an outside agency. 

VIII. TYPES OF SOCIAL SERVICE ACTIVITIES. 

The work of the several social service depart- 
ments has been summarized under nine heads, on 
the basis of the information given as to what con- 
stituted the problem in each of the 675 cases ana- 
lyzed. The main problems thus ascertained were 
found to be: 1. Home nursing . and instruction. 
2. Followup work with the patients to secure their 
return to the clinic for further treatment and ex- 
amination. 3. Securing employments suitable to 
their conditions. 4. Arranging for family readjust- 
ment so as to enable the patient to go either to a 
convalescent home or to a sanatorium, and to take 
care of the family during the absence of the father 
or mother. 5 : Convalescent care of the patients: 
6. Institutional care. 7. Additional clinic attention 
either at the same clinic or at some other clinic 
where the condition of the patient might be treated 
to better advantage because of the ampler facilities. 
8. Securing financial aid for the patient and the 
family. 9. Investigating the various bearings of 
environment with reference to the patient's con- 
dition. 

The following is a summary of the various types 
of social service work done in the twenty-one in- 
stitutions included in the present survey: 

Xiimbcr Percent 



Home Nursing and Instruction.... 221 32.9 

Follow up 47 6.9 

Employment 17 2.5 

Family Readjustment '25 3.7 

Convalescent Care 77 11.7 

Institutional Care 117 17.3 

Additional Clinic Care 45 6.6 

Financial Aid 94 13.9 

Investigation as to Problem 3(F 4.5 



Total 675 100 



- Two cases, problem not stated. 

According to this classification the largest num- 
ber of cases, or 32.7 per cent., were in the group 
of home nursing and instruction. In other words, 
almost one third of the cases, in the judgment of 
the social service workers, required sanitary super- 
vision in the home, instruction in hygiene and diet, 
home nursing, or direction as to the carrying out 
of treatment. In this respect four institutions, of 
which three are large general out patient depart- 



January 8, 1921.] 



LONDON LETTER. 



69 



ments of hospitals and one«Q detached general dis- 
pensary, show the largest percentages. 13.8 per 
cent, of the patients were financially harassed and 
the social service departments felt that their func- 
tion was to step in and obtain for the families the 
needed aid; three institutions, one a large general 
out patient department, one a university clinic, and 
the third an institution for the treatment of special 
conditions, have the largest relative number of 
financial aid cases. 

Providing institutional care was another of the 
most frequent functions of the social service de- 
partments; 17.3 per cent, of the cases in the study 
received this kind of attention from the social ser- 
vice. Another large group, constituting 11.7 per 
cent, of the total number, received convalescent care. 
In 6.9 per cent, of the cases the function of the 
social service department was to follow up the 
patients and bring them back to the clinics. This 
was found being done at only seven institutions, 
and chiefly in connection with cases 'of tuberculosis 
and poliomyelitis. 

The finding of employment and making family 
readjustments are evidently not among the frequent 
duties which fall upon the social service depart- 
ments as they function at the present time. It is 
surprising that in only 2.5 per cent, of the cases 
the chief problem was the need of arranging a 
change of occupation for the patients, and likewise 
in only 3.7 per cent, of the cases the chief problem 
was the need for family readjustment due to the 
illness of either the breadwinner or the mother. 

REFERENCES. 

1. Davis and Warner: Dispensaries, New York, 1918, 
p. 101. 

2. Cannon, Ida: Social Work in Hospitals. New York, 
1913, p. 1. 

3. Loc cit., p. vii. 

(To be concluded.) ■ 

LONDON LETTER. 
(From our own , correspondent.) 

Medical Men Organising in Great Britain — Treatment of 
Eye Diseases in Great Britain — The Coal Smoke Curse 
and Its Conquest in America — Care of the Tuberculous — 
Institute of Physics— Epidemic Diseases in London. 

London, December jgjo. 
It has long been evident that unless medical men 
organized to protect their own interests they 
would be unable to carry any weight. Politically 
the medical profession is practically impotent and 
as the Ministry of Health is largely a political body, 
and as the bulk of the inhabitants of Great Britain 
can call upon the services of medical men under 
the insurance scheme, if doctors are not strong 
enough to resist they will be almost at the beck and 
call of their patients. It must be borne in mind 
that those who can claim medical treatment under 
the insurance act are not especially favorable to the 
medical profession, in fact, a considerable propor- 
tion is frankly antagonistic. In the event of a clash 
between medical men and their clients, it might 
go badly with the doctors. The Ministry of Health 
after all, is a department of the Government, and 
its actions are likely to be swayed by political 



motives. Those who can wield the power will have 
the best chance of getting their own way and per 
contra. The medical men have not the power at 
the present time and are therefore likely to be 
imposed upon. 

it is encouraging to learn that medico])olitical 
unions are being formed. The inaugural dinner of 
the North London branch of this union was held on 
December 2d, last. Among those present was Dr. 
E. S. S^ancomb, president of the union, who spoke 
in part as follows : He said the object of the union 
was twofold, viz., to do their duty to the communit\' 
and to protect themselves against too much red tape 
and interference. It was not their desire to oppose 
progress. In the past few years they had seen pro- 
cessions of the men who fought in the air and on the 
sea and under the sea and on the land, but they had 
not seen a procession of the medical men who were 
engaged at the front abroad, and at the home front, 
looking after our sailors and soldiers, their women 
and children, and the community generally. If it 
had not been for medical science we should have 
been beaten to a frazzle. If the medical men could 
organize during the war for the good of the com- 
munity, they could organize with the same object 
now that we had peace, at least comparative peace. 

At the present time the medical officers of many 
important boroughs were paid considerably less than 
other officials, such as \he gentlemen who looked 
after the trains and the electricity. The health of 
the community was the real wealth of the com- 
munity. Their object, in brief, was not to strike 
as the term v/as generally understood, but, if neces- 
sary, to strike against Government parsimonv and 
red tape and interference. The doctors undoubtedly 
were in a position to understand the needs of the 
community better than many other gentlemen who 
found their way to the House of Commons, and 
the doctors should be better represented there. In 
the organization of the Ministry of Health and its 
work the medical profession as a whole had been 
ignored. That was because medical ITICII lis. d hither- 
to failed to combine in any way. 

Dr. Nathan Raw said he was certain if other 
branches of the union were fomied in the same 
vigorous way in which the North London branch 
had been brought into existence the doctors of the 
country would soon make their voices heard, not 
only in London, but throughout the country. In- 
deed, if the medical profession could unite on one 
policy they could practically rule the country. The 
doctors in the. House of Commons at the moment 
were so few that they carried less weight than 
many sections of the community with much less 
responsibility. He therefore hoped to -see doctors 
combining all over the country, and thinking out 
great policies for the good of the country and for 
the protection of their dignity and privileges. 

Little was known concerning the surgery of the 
eye in Great Britain until the expedition into Egypt 
under Sir Ralph Abercrombie took place following 
the advance of the French into the land of the 
pyramids led by Napoleon Bonaparte. The British 
troops became the victims of contagious ophthalmia, 
then and now widely prevalent in that country, and 



70 



LONDON LETTER. 



[New York 
Medical Journal. 



brouglit back that scourge into (ireat Britain. In- 
capacitated from further fulfiUing their military 
duties, the disease was spread by these men through- 
out the length and breadth of the land. 

In the Daily Telegraph, December 4, 1920, is 
given an interesting account of the beginnings and 
development of scientific eye treatment in this 
country. As said before, little was known of eye 
treatment in the years about 1802. It was largely 
an open field for quacks and impostors. *A young 
surgeon, John Cunningham Saunders by name, was 
one of the first to realize die need for a closer study 
of the eye and its diseases, and he proposed the 
foundation of the ]\Ioorfields Eye Hospital, of 
which he was the first surgeon and which has 
established its fame as an institution of its kind 
second to none. Although no longer in Moor- 
fields, having been removed to more spacious and 
adequate premises, and although officially it is the 
Royal London Ophthalmic Hospital, it is known in 
all parts of the English speaking world as Moor- 
fields. Postgraduate students not only come from 
Great Britain, but surgeons from America, Canada, 
and from practically all quarters of the globe, to 
this London eye hospital. A touching tale is told 
of its connection with America in its early days. 
Dr. Edward Reynolds, from Boston, Mass., ar- 
rived in the year 1816 to pursue his studies at 
Moorfields. On his return to America he found 
his father blind from cataract in both eyes. Forti- 
fied by the skill and experience he had gained in 
London, he operated and restored sight. It is said 
that the operation for cataract was invented and 
first performed in IMoorfields. 

The object of the article referred to was to call 
attention to the desperate plight in which this 
institution finds itself from the financial viewpoint. 
For 115 years the hospital has been doing 
its healing work, saving the sight of the young, 
restoring the sight of the aged, alleviating pain, 
making good the eye injured by accident, sending 
citizens from its doors well capable of earning 
their living who, but for its ministrations, might 
have become blind dependents of others. But as 
is the case with all other institutions here for the 
care, relief and treatment of the sick and injured, 
Moorfields is so hampered in its work through lack 
of funds that unless money is quickly forthcoming 
its capacity for good will be wrecked. 

This year investments of the face value of £8,000, 
given or acquired when four per cent, was good 
return for money, will have to be sold for what 
they will fetch. Maintenance costs have doubled. 
Salaries, which for nine months in 1917, after three 
years of war, were £3,013 ($15,065), are now 
£5,701 ($28,505). The burden of rates, £820 
($4,100) in 1914, is now £1,280 ($6,400), and will 
be higher. It may be mentioned that no one is 
ever kept out because he or she cannot pay, but in- 
patients are now asked to pay what small sums they 
can afiford. As for outpatients, contributions are 
still voluntary. An appeal is now being issued for 
£100,000 ($500,000), to which it is hoped there 
will be response in America, India, and Canada, as 
well as in Great Britain. While, of course, all 
British hospitals are in a desperate condition finan- 



cially, and while equall^', of course, all are deserving, 
the big London eye hospital is perhaps more deserv- 
ing than many. Blindness is one of the most ter- 
rible afflictions to which the human race is subject, 
and is frequently easily prevented. For example, 
ophthalmia neonatorum, if not treated in time, 
inevitably leads to blindness. On the other hand, 
if treated early it is generally amenable to proper 
treatment. In the case of threatened loss of sight, 
the old adage, "prevention is better than cure," is 
more emphatically true than in most diseases, and 
preventive treatment is assuredly better in every 
respect than caring for those who have become 
irretrievably blind. Therefore, Moorfields should 
not be allowed to lose its capacity for good. Such 
an event would be a national disaster. 

The financial state of the hospitals is a question 
which is now arousing concern in all circles, and 
is a problem which must be met, and met soon. 
The voluntary system, if it has not broken down 
entirely, is inadequate to cope with existing con- 
ditions. However, steps are being taken to deal 
with the situation, and when matters in this direc- 
tion are more matured, they will be discussed in 
succeeding letters. The hospital problem is the one 
of the hour, so far as the health of the people and 
the medical profession are concerned. 

* * * 

On more than one occasion the evils of coal 
smoke in the cities of Great Britain in general and 
of London in particular, have been discussed in 
these letters, and it has been pointed out that its 
continuance is mainly due to lack of obvious 
methods of prevention. That it is unhygienic can- 
not be denied, and that it is decidedly unpleasant 
is just as patent, but the British public appears to 
endure the infliction with equanimity if not with 
indifference. It is an evil to which all are inured, 
one perhaps almost hallowed by long use. How- 
ever, there are a few in this country who now and 
then lift up their voices in protest against such an 
unhealthful custom, and there are even signs that 
some, at least, of city, dwellers are beginning to 
rouse themselves from their lethargic attitude. 
Among these would-be reformers is Dr. C. W. 
Saleeby, who, in season and out of season, has 
never hesitated to denounce the practice of allow- 
ing the air to be laden with particles of coal dust, 
to the hurt of those who suffer from bronchial or 
other respiratory diseases, and to the discomfort 
of all. Dr. Saleeby delivers himself of his views 
in the correspondence columns of the Medical Press 
and Circular, November 24, 1920. As he has only 
recently returned from a second visit to America, 
he is able to compare the conditions as regards the 
smoke nuisance in the cities of that country with 
those which prevail in London. The comparison is 
not flattering to the hygienic methods of British 
sanitarians. He draws attention to the fact that 
under the New York regulations no one burns soft 
coal, but that while in the British health act black 
smoke is forbidden, the law is so easily evaded that 
it is virtually a dead letter. He further makes tlie 
pungent remark that if the industrial chimney can 
be rendered innocent in Pittsburgh, as according 
to him it has been rendered innocent, it need be 



Januar, 8, 1921.] 



LONDON LETTER. 



71 



noxious nowhere. He goes on to show that the 
domestic chimney sins not at all in America, be- 
cause the women of the United States and Canada 
live in houses where just a little science and just 
a little sense have been invoked. 

A Departmental Committee on Air Pollution by 
Smoke and Other Noxious Vapors, was appointed 
by the Ministry of Health early in this year, and 
has pubHshed an Interim Report, in which Dr. 
Saleeby declares every one of the contentions laid 
before it was accepted. The committee recommends 
that no new house should receive official approval 
unless it be designed so as to be smokeless. How- 
ever, despite this recommendation, the public seems 
as indifferent as ever to the coal smoke evil. Dr. 
Saleeby, therefore, writes in the hope that the small 
proportion of British citizens who have had training 
in the elementary laws of life may concern them- 
selves in a sanitary reform which may make the 
air and light supply of British cities comparable 
in quality with their water supply, in which matter 
Britain led the world as far as she now lags behind 
in those others no less important. 

* * * 

It has been widely announced in this country that 
sanatorium treatment of the tuberculous is a failure. 
The Committee of the Sanatorium Benefit of the 
L6ndon Insurance have had large experience of 
this form of treatment, having been responsible 
from 1912 to 1920 for the provision of sanatorium 
treatment for more than twenty thousand tuber- 
culous persons. Dr. Henry Lesser, chairman of 
the Insurance Committee of the County of Lon- 
don, contributed recently a letter to the public press 
in which he points out the committee's medical 
adviser, Dr. Noel Bardswell, has submitted reports 
on the treatment furnished by the committee and 
the lessons to be derived therefrom. Above and 
beyond all question there emerges the simple fact 
that sanatorium benefit is a failure. Of the patients 
whose treatrnent was commenced by the committee 
during the year 1914, over seventy per cent, were 
dead before the end of 1918. Dr. Lesser contends 
that obviously to continue the present arrangements 
for sanatorium treatment would be vmeconomic and 
inexcusably wasteful. Prominent men who have 
jgiven their lives to the study of this terrible problem 
in its social, economic, and medical aspects, are 
impressed with the urgent need for certain improve- 
ments, among which are : Encouragement of experi- 
mental colonies and settlements ; experiments on the 
lines of local work centres ; the subsidy of after- 
care work to be limited to one or more selected 
boroughs. 

It was understood that the Ministry of Health was 
introducing a Tuberculosis Bill, clauses of which 
provided for the provision of village settlements or 
colonies for the tuberculous and the care and assist- 
ance of tuberculous persons and their families. It is 
now proposed to omit these clauses, mainly on the 
grounds of economy. It is argued, however, that 
economy of this kind is quite false economy. 
Sanatorium treatment has been given a lengthy 
trial, and has proved, on the whole, a complete 
failure. On the other hand, the colony and village 
settlement system seems to be successful. 



The best example in Great Britain of this system 
is at Papworth, near Cambridge. The writer a 
short time ago visited this colony and inspected 
it closely. He was greatly impressed with all he 
saw, and intends to send an account of the Pap- 
worth Sanatorium, colony and village settlement, 
to the New York Medical Journal. The Min- 
ister of Health is aware that the sanatorium by 
itself is of little or no use, and he also knows that 
the colony and village settlement system has, on a 
comparatively small scale, it is true, answered well. 
It is a financial question, but as said before it does 
not seem to be sound economy to cheesepare when 
dealing with tuberculosis. The tuberculous person 
working with his fellows at a certain stage of the 
disease is a menace. For the sake of the community 
and for his own sake it is best that he should be 
segregated, and what more effective mode of segre- 
gation can be devised than by placing him or her 
in colonies, industrial or agricultural, and village 
settlements, where he can render himself self- 
supporting or partly so, and where he will be no 
source of danger to his fellowmen, which is, after 
all, of the first importance. . 

* * * 

It was announced recently that the Institute of 
Physics has been incorporated and has commenced 
to carry out its work. The object of this institute 
is, on the one hand, to secure the recognition of the 
professional status of the physicist, and, on the 
other hand, to coordinate the work of all the societies 
interested in physical science or its applications. 
Five of these societies are already participating, 
namely, the Physical Society of London, the Optical 
Society, the Faraday Society, the Royal Micro- 
scopical Society, and the Rontgen Society. Two 
hundred fellows are included in the first list of 
names. Sir J. J. Thompson, the retiring president 
of the Royal Society, has accepted the invitation 
of the board to become the first and at present the 
only Honorary Fellow. Sir Richard Glazebrook, 
F. R. S., is the first president of the institute. 
Physics is beginning to take its rightful place in. 
the education of the medical student. It is recog- 
nized that a knowledge of physics is essential in 
a thorough medical education, and already some of 
the British medical schools have established chairs 
of physics. 

* * * 

In answer to a question asked in the House of 
Commons recently with respect to the prevalence of 
diphtheria, scarlet fever, and influenza in London, 
Dr. Addison, the Minister of Health, replied that 
scarlet fever and diphtheria had been exceptionally 
prevalent in London during this autumn, but both 
diseases were of an exceedingly mild type, and the 
death rate in each case was far below that experi- 
enced in previous epidemics. There was no evi- 
dence of the existence of epidemic influenza in 
England at the present time. The origin of these 
waves of zymotic disease was obscure. Similar 
though more fatal outbreaks occurred in 1892 and 
1893. He was glad to say that existing machinery 
and the available hospital accommodation had 
proved equal to the task of coping with the present 
outbreaks. 



Editorial Notes and Comments 



NEW YORK MEDICAL JOURNAL 

INCORPORATING THE 

Philadelphia Medical Journal 
and the Medical News 

A Weekly Review of Medicine. 

Address all communications to 
A. R. ELLIOTT PUBLISHING COMPANY, 
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Entered at the Post Office at New York and admitted for transpor- 
tation through the mail as second class matter. 

NEW YORK, SATURDAY, JANUARY 8, 1921. 

THE EVOLUTION AND PROGNOSIS OF 
ABDOMINAL AORTITIS. 

The evolution of abdominal aortitis is essentially 
variable, as everything depends upon concomitant 
lesions and the etiology of the process. From the 
viewpoint of the progress of the affection the aortitis 
may be distinctly localized or descending. The in- 
vasion is different according to whether the case is 
one of acute aortitis or a chronic process from the 
onset or following an acute lesion. 

Acute aortitis sometimes develops very rapidly, 
the affection reaching its height in a few days, but 
when it assumes the chronic type its onset varies in 
character and is generally slow in developing. In 
the majority of cases the process is localized, re- 
maining limited to the portion of the vessel extend- 
ing from the subdiaphragmatic part to the bifur- 
cation of the iliacs. The process is often localized 
but extensive, as is evident from many cases where 
both the aorta and the iliacs were sensitive and pain- 
ful, while in an instance recorded by Teissier a dou- 
ble murmur heard over the umljilicus could also be 
heard over both iliacs, which were painful but 
ended there. As a third possible evolution abdomi- 
nal aortitis should be mentioned following a slowly 
descending progress, as in the case of Roque and 
Corneloup, where the process, at first seated in the 
ascending portion of the aorta, extended progres- 
sively, at first being thoracic and then abdominal. 

The evolution of the disease depends on the con- 
comitant lesions and is essentially related to them. 
Usually the process is of moderate intensity without 
any alarming symptoms, but in other cases the symp- 



toms presented are so acute that the process must be 
regarded as a serious type of the affection. The 
disease may undergo an evolution in distinct recur- 
rences, although this is not common. The chronic 
forms may succeed the acute type, but generally 
these cases, when they first come under observation, 
have been going on for months or even years, and 
it is only after this lapse of time that the symptoms 
become manifest. The evolution of these chronic 
cases is occasionally effected by painful paroxysms 
occurring at distinctly fixed intervals ; or the evolu- 
tion may be slow with persistent pain, and although 
this is ameliorated by treatment it does not entirely 
subside. 

The prognosis of the acute cases quoad vitam is 
usually good. In the chronic cases there are dis- 
turbances resulting from atheroma, in which case 
the prognosis is dependent upon the latter lesion. 
Atheroma, "the rust of life," as Potain called it, 
prepared the way for spontaneous rupture of the 
vessel, and this accident occasionally takes plaoe. 
Consequently the prognosis in cases of chronic ab- 
dominal aortitis should be guarded. A bad prog- 
nosis should naturally be made when the aortitis is 
complicated by either gangrene or hemorrhagiparous 
lesions, an infarctus often being the cause of death, 
and when the abdominal aortitis is complicated by 
an aortitis in the upper portion of the vessel, we 
must rely upon the heart for the prognosis. 



NEW PROVISION FOR THE HOSPITAL 
CARE OF THE SICK IN MIND IN* CANADA. 

By means of juvenile courts, observation homes, 
big brother and big sister movements, psychopathic 
hospitals, the whole Dominion of Canada is taking 
progressive steps toward ameliorating conditions as 
they are to be found among mental and nervous 
abnormal cases, other than those congenital cases or 
those suffering since birth, and the certified insane. 
Dr. Helen Boyle, the distinguished authority on 
mental disease, who has recently lectured in different 
sections of the Dominion, has reawakened the con- 
science of legislators and others to the crying needs 
of the problem as to how to care for Canada's un- 
fortunates. 

Some years ago, perhaps five or six, the Govern- 
ment of Ontario appointed Mr. Justice Hodgins, of 
Toronto, to make a report on the whole situation of 
the feeble minded as it affected that province. His 
report has now been before the present Government 
more than a year, with the result that it appears to 
have been pigeonholed. Some aver that the action 



January 8, 1921.] 



EDITORIAL ARTICLES. 



73 



of the Ontario authorities, or, rather, the inaction, 
is greatly hindering the handling of the problem of 
the feebleminded all over the Dominion. Less than 
three years ago the Canadian National Committee 
for Mental Hygiene" was called into being ; and the 
most recent piece of work done by that committee 
was the making, at request, of a mental hygienic 
survey of the province of New Brunswick. It in- 
cluded an investigation of some eighteen institutions 
caring for insane, feebleminded, delinquents, depen- 
dents, and unmarried mothers, together with a 
mental examination of five thousand children attend- 
ing eleven representative public schools in that 
province. Of course, the survey was made with the 
view of determining the nature and extent of the 
problem there, what facilities were available for deal- 
ing with the situation, and the needs for the future. 
New Brunswick is one of seven provinces that have 
called upon the Canadian Hygienic Committee for 
assistance along these selfsame lines; and in many 
instances the advice of the committee has been ac- 
cepted, and now two provinces are spending one and 
a half million dollars on mental hygiene activities. 
Thus, while more adequate facilities are being pro- 
vided, more scientific treatment has also been made 
available ; more preventive measures have been 
adopted and more ctistodial care supplied. 

In three years the Canadian committee has in- 
spected, outside of Toronto, thirty-six provincial and 
county hospitals for the insane, twenty jails, seven- 
teen industrial homes, and eleven homes for de- 
pendents. The inspection involves a complete men- 
tal examination of all inmates with the making of all 
necessary tests. There have also been examined 
2,405 children attending private schools, and 5,500 
immigrants and 350 unmarried mothers. The find- 
ings have been presented to the various govern- 
ments concerned with resulting needed changes. 
One of the particular presentments has been that 
concerning immigration ; and the assurance may now 
be given that the Federal Department of Public 
Health is handling that aspect of the problem with 
intelligence and exactitude. For the first time in 
Canadian history physicians with a knowledge of 
psychiatry are inspecting immigrants at ports of 
entry, and within the last few months have rejected 
many with sufficient evidence of unsound mind to 
warrant their deportation. 

It is interesting to note that several psychopathic 
hospitals are to be erected in various parts of 
Canada; and only recently the Ontario Government 
has acquired the Speedwell Military Hospital at 
Guelph for the purpose of additional accommoda- 
tion for Ontario's insane. In the many new institu- 
tions shortly to be called into active service, cases 



of mental disease will be accepted as easily as are 
admitted into the wards of a general hospital those 
with physical derangements. They will be observed 
and treated for a limited period ; and if the experi- 
ence of the Winnipeg Psychopathic Hospital can be 
taken as a criterion, more than eighty per cent, can 
ultimately be returned to their own homes. Such 
practice will obviate the necessity of sending many 
to hospitals for the insane, with distress to friends 
and relatives alike, as well as obviating the horrible 
possibility of being confined in common jails with 
the criminal classes — a practice which might well be 
styled an anathema of any civilization. During the 
last three years the Canadian Mental Hygienic Com- 
mittee has carried on its work on gifts of some 
$90,000, and its requirements for the next three 
years are estimated at $135,000. It is believed that 
Canada, with earnest efifort, will soon have sur- 
mounted the problem of the mental defective, the 
dangers involved in neglect of this matter, and a 
saner, wiser policy of broad and universal adapta- 
tion to the needs of her unfortunates. - 



PHYSICIAN AUTHORS: DR. GEORGE 
CRABBE. 

George Crabbe is practically unknown to readers 
of the present day, and literary reviewers have a 
hard time of it trying to explain why this is so. Why 
has a poet and realist of Crabbe's acknowledged 
skill gone so completely out of vogue — especially 
one who was praised with such unwonted enthusiasm 
as was Crabbe? "Though Nature's sternest painter, 
yet the best," said Byron. "His poems are the most 
touching in our language," said Cardinal Newman. 
"One of the masters and renovators of poetry," was 
Taine's verdict. "The Hogarth of modern bards," 
said Dibdin. "Crabbe's poems will last from their 
combined merit as poetry and truth," said Words- 
worth. Edward Fitzgerald, of Omar fame, was 
even. more ardent than these. Praise of Crabbe is 
scattered profusely throughout his many volumes of 
correspondence. Tennyson, Dickens, Macaulay, 
Jane Austen, Leslie Stephen — in fact, there is 
scarcely an English man of letters of the last hun- 
dred years who hasn't spoken his word of praise 
for Crabbe. He has been described as "the truest 
realist in the English language" and a "fine and 
genuine poet with a clear vision of life." Every- 
body who has read him puts him among the classics, 
but, alas ! it is hard to find anybody who has read 
him. 

Three outstanding reasons for Crabbe's lack of 
popularity, in face of all this encomium, have been 
advanced. First, he wrote in verse when he should 



74 



EDITORIAL ARTICLES. 



[New York 
Medical Journal. 



have written novels. He could have been another 
Thomas Hardy. The author of Tcss of the D'Ur- 
bcrvilles gives Crabbe the credit of having been the 
most potent influence that affected his work. 
Crabbe's forte was the novel, had he but known it. 
His poems are novels in verse — good stories that 
leave a vivid impression on the mind. "Crabbe's 
genius was unfortunate in finding no other vendible 
vehicle for his thought than verse," said Andrew 
Lang, "for his natural bent was the modern 
realistic novel on the squalor, sufferings and sins 
of the neglected rural poor." Lang touches upon 
the second principal reason for Crabbe's oblivion. 
His genius was "too grim and stern" ; his gift, 
though perfect, was too sinister. And yet, his 
admirers will tell you there is buoyant humor and 
gaiety of heart in Crabbe's work. Sir Walter Scott 
on his deathbed said : "Read me some amusing 
thing; read me a bit of Crabbe," and chuckled and 
said "Splendid !" as it was being read. The last 
big reason for Crabbe's eclipse is that his style, as 
Taine poinj^ out, was too classical. His general 
literary form and manner hurt his popularity. Pope 
was his model. All his tales are written in the 
rhymed couplet of the Pope school. And so he was 
nicknamed "a Pope in worsted stockings." It has 
been said, also, that he diverges too much from the 
trend of modern thought. Somehow these explana- 
tions fail to explain, but the fact remains that 
Crabbe is little read. He is not, of course, wholly 
neglected. He has his little coterie of staunch 
admirers. : Oliver Elton optimistically says that 
"his day may ripen again." The chance of this 
seems remote. He is perhaps not destined to be 
popular again, but his place in English literature is 
secure, and for those who like poetical pictures of 
the grim and depressing side of life he can be safely 
recommended. 

Crabbe was born on Christmas eve, 1754, in 
Aldeburgh, on the Suffolk coast, and died on Feb- 
ruary 3, 1832. His early life was one of bitter 
poverty. After a few years of schooling he began 
helping his father as a worker on the docks and in 
warehouses at Aldeburgh. At fourteen he- was ap- 
prenticed to an apothecary and at fifteen was 
api)renticcd to a surgeon. Later on he practised 
medicine and surgery in a humble way in Aldeburgh 
and Ipswich, but his success was small and his 
penury extreme. Again he became a warehouse 
laborer, but continued to study medicine and in 1777 
went to London, where he spent nine months work- 
ing in hospitals. In a letter to his sweetheart, 
Sarah Elmy, whom he always addressed as "Dearest 
Mira," he mentioned that he had to sell his surgical 
instruments to pay his bills. It is related that while 



in London he had a narrow escape from being haled 
before the Lord Mayor on a charge of being a 
resurrectionist. His landlady, while tidying his 
room, found the remains of a child which Crabbe 
had obtained for purposes of dissection, and thought 
it was the body of a child of her own who had died 
a fortnight before. Fortunately Crabbe happened 
to enter and was able to allay her fears, since the 
face of the infant had not been marred. After his 
London experience Crabbe again returned to Alde- 
burgh to practise, but again was unsuccessful, and 
in 1780 definitely abandoned medicine and went to 
London to try his luck in literature. At eighteen 
he had won a prize for a poem, Hope, published in 
IVheehle's Magazine, and a moral poem of his, 
Inebriety, had been published in 1775. He induced 
a London publisher to issue TJie Candidate, but it 
was a failure and Crabbe went hungry many a day. 

It is said that "Dearest Mira," whom he married 
in 1883 after an engagement of eleven years, gave 
him some financial aid. In such desperate straits 
was Crabbe that he sought to enlist the aid of influ- 
ential pohticians. In this way Edmund Burke be- 
came interested in him, and secured the publication 
of The Library in 1781. Besides, Burke got Crabbe 
a "living" as an Anglican priest. He was or- 
dained in August 1782, and flirough Burke's in- 
fluence eventually became chaplain to the Duke of 
Rutland. His first successful poem was The Vil- 
lage, published in 1783. It was written to deride 
the idyllic sentimentalism of Goldsmith's Deserted 
Village, but The Deserted Village seems to have 
sustained the shock. His next was The Newspaper. 
Nothing more appeared until his Poems in 1807. 
These were followed by The Parish Register, in the 
same year, The Borough, three years later ; Tales in 
1812 and Tales of The Hall in 1819. A large num- 
ber of other tales in verse, published posthumously, 
appear in his Works. His only prose writing was 
a few medical disquisitions of a minor nature. 



UNREGARDED WARNINGS. 

There is no post helium for doctors, for theirs 
is an unending fight against greed, ignorance, and 
disease. One doctor who served during the war, 
in France, has had to take a post at a mining station 
in Mexico and says : "Bolshevist literature is being 
circulated among the soldiers urging them to com- 
bine with workmen to seize productive industries." 

The seed is being sown. What is the mining 
company doing even to mend existing health con- 
ditions? Nothing. "There is no water near the 
mine, and no springs nor wells except on the other 
side of the mountain. The company brings water 



January 8, 1921.] 



EDITORIAL ARTICLES. 



by railroad in tanks every day and fills the tanks 
at hospital and American homes at cost of about 
five hundred dollars a month. The poor Mexicans 
have no provision, and carry water for family use 
and for their animals from tanks about three or 
four miles away and pay two cents a bucket. 
Naturally there is Httle or no bathing, and I have 
seen them washing several garments in two quarts 
of water. Discontent is spreading. We may have 
some excitement here, as there is considerable 
bubonic plague about sixty miles down the valley. 
It has been gradually encroaching on the highlands 
from Tampico for about a year, and is slowly mov- 
ing towards the interior. The company sent us 
some plague serum, but I have little confidence in 

it-" 

Here is a case of a competent medical officer 
hopelessly handicapped by insanitarv- conditions he, 
alone, cannot mend, and who sees trouble ahead in 
advancing plague. Added to this he sees Bolshev- 
ism threatening, not unnaturally, among natives 
who see rich mining companies take all they can 
get at the cheapest cost and leave the countrv- worse 
for their coming. 



EDUCATING THE STAFF. 

It is not always realized that all light thrown 
on the condition of asylum and prison inmates must 
come from those on the staff, and in judging fairly 
a few reported cases of bullpng or neglect it must 
be remembered that the nature of the insane and 
criminal, their dogged determination to annoy those 
in authority, their profanitv', their obscene language 
and disgusting habits when such exist sorely try 
the patience of the most enthusiastic in reform. 
We are not speaking generally. There are many 
in an asylum who seem sane, many in a prison 
who appear not guilt}-. 

How far education has influenced the staff of 
the New Jersey State Hospital can be seen by The 
Psychogram, issued monthly, and for which the 
patients w-rite, not only write for, but print. The 
October number is specially good in its contribu- 
tions and clear pictures, the whole number is cheery 
in its descriptions of the everyday happenings, its 
poems and sketches. Only those who have worked 
in an asylum can appreciate what it means to bring 
out a paper even with the sanest patients' help. 

The same feeling of respect should be felt for 
those of the staff in the Minnesota State Prison, 
through whose care The Mirror is issued, and for 
which the prisoners write. The very ignorant often 
imagine the ordinary criminals as always intent on 
evil, the more charitable imagine them somewhat 
weak in intellect, whereas there are those who com- 



mit the most absurd and often atrocious crimes who 
cannot be classed as feebleminded ; they may even 
be supernormal in mentality. 

These humane efforts to improve the wearj- days 
of those detained within asylum and prison walls 
should be welcomed even by the mean man, for 
they will gradually save the State much money in 
taxes for institutional upkeep. 



NOT WANTED. 

We have had too much of problems being tftrmed 
unsolvable. Those who deem one most so often 
know the remedy and will not apply it for fear of 
antagonizing property owners, politicians, the church 
or friends, and such men are now found urging 
that the impecunious tuberculous should not be sent 
to Texas .as there are no advantages in the climate 
and light work is scarce. These socalled facts the 
various boards of health desire to have circulated 
with a \-iew to deter newcomers. They have been 
faced with the problem of the impecunious tuber- 
culous and this is their solution. 

Now the truth is that with increasing knowledge 
of disease, property owners in Texan towns have 
begun to recognize the disadvantages of having a 
State sanatorium near their land, and even land- 
ladies advertise their rooms with a warning, "No 
tuberculous taken." As to ad^'antages through cli- 
mate, anyone who has lived at a place — say. El Paso 
— has known and seen what a sojourn there will 
do. How men who arrived limp, listless, wistful, 
have soon been able to sit on the plaza or even 
climb up on to the Meza. Moreover, the sanatoria 
for the rich just pile up e\-idence of its healing 
powers. As for light work, there is always plenty 
in a rising communitv% and the hundreds of wooden 
bungalows in course of erection in a new Texan 
town generally provides it. To guard a town against 
undesirable visitors is natiu-al, often justifiable, but 
to use mendacity as a weapon is rather a low form 
of warfare. The problem is, in realitv-, not one at 
all, but merely a question how to keep up the price 
of land and property if a disease is allowed to 
hover and finally settle in the State. The answer 
is to have a frsLnk declaration of how the settlers 
obtained their rights to lands. Part of the early 
procedure was to advertise the climate as health, 
giving, and to disparage it when it came to a 
question of taxes for a State sanatorium, or when 
stifficient of the wealthy tuberculous had purchased 
land and settled there. 



BURGL.\RY ANT) DENTISTRY. 
In these days when science figures so largely in 
the work of detecting crime and often in the task 
of committing it, the burglars would do well 
to establish some evening lectures bearing on medico- 
legal work. Fagin, in Oliver Twist, had classes 
for the quick theft of handkerchiefs and jew-elrv-, 
but the modem criminal is more intent on knowing 
about the manufacture of bombs and poisons and 
the distinction between human and animal blood 
smears. At any rate, a word of advice as to fre- 
quently seeing a good dentist might not be out of 



76 



NEWS ITEMS. 



[New York 
Medical Journal. 



place. A burglar made a murderous attack on a 
bailiff and his wife in their lonely cottage, but 
escaped. A false tooth was found on the floor by 
the local policeman, who treasured it up, and, some 
time after, caught the man belonging to the tooth. 
Doubtless, the man thereafter sought a more skilled 
dentist. 



News Items. 



Italians Plan Hospital. — On December 22d 
over two hundred Italian citizens of Brooklyn held 
a meeting for the purpose of starting a drive for 
the collection of $350,000 to build a hospital in 
Kings County. 

Human Rabies in New York. — Six cases of 
human rabies were reported to the Department of 
Health of the City of New York during the years 
1919 and 1920. They all occurred in chiPdren four 
years of age, and all were fatal. 

Polish Doctors Victims of Typhus. — Cable dis- 
patches from Warsaw state that Poland lost four 
hundred doctors from typhus fever last year. There 
are only 4,000 doctors now in the country, which 
has a population of 28,000,000. 

Medical Monthly Changes Name. — With the 
December issue the name of the Medical Council, 
of Philadelphia, was changed to the American 
Physician. The publishers announce that the change 
is in name only, the organization remaining the same. 

Professor Bumstead Dies on Train. — Dr. 
Henry A. Bumstead, professor of physics at Yale 
University, died on Friday evening, December 31st, 
on board the train while on his way to Washington 
from Chicago. He was fifty years of age. He was 
on leave of absence from Yale, serving as chairman 
of the National Research Council in Washington. 

Western Surgical Association. — At the thir- 
teenth annual meeting of this association, held 
recently in Pasadena, Calif., the following officers 
were elected : Dr. Charles D. Lockwood, of Pasa- 
dena, president; Dr. Harry Ritchie, of St. Paul, 
vice-president ; Dr. Warren A. Dennis, of St. Paul, 
secretary (reelected). Next year's meeting will be 
held in St. Louis. 

New Work for League of Red Cross Societies. 
— The Council of the League of Nations has re- 
quested the League of Red Cross Societies to supply 
the personnel and materials to protect the health 
of the international force which will go to Vilna 
to supervise the plebiscite to determine the sov- 
ereignty of that district. Colonel Henry A. Shaw, 
of Worcester, Mass., has been sent to Vilna to make 
the necessary arrangements. 

Fatalities from Automobile Accidents in Lon- 
don. — Automobile vehicles of all classes killed 
fifty-one persons in London in November, 1920, 
compared with fifty in November, 1919. The Lon- 
don referred to is the metropolitan police district, 
which extends over a radius of fifteen miles from 
Charing Cross, and covers an area of roughly seven 
hundred square miles. About seventy per cent, of 
the casualties occurred in the day time, and thirty 
per cent, at night. Only two fatalities happened in 
November in the city proper, which is an area of 
just over a square mile around the Mansion House. 



Typhus Fever on Ocean Liner. — A case of 
typhus fever was found on the steamship United 
States as the vessel left Copenhagen, Denmark, on 
November 18th. The patient, with four contacts, 
was removed from the vessel at Christiana, Norway, 
and the vessel sailed from that port for New York 
on November 19th. 

Southern Gastroenterological Association. — 
At the annual meeting of the Southern Gastro- 
enterological Association, held recently in Louis- 
ville, Ky., Dr. George M. Niles, of Atlanta, Ga.. 
was elected president. Dr. Marvin H. Smith, of 
Jacksonville, Fla., was elected vice-president, and 
Dr. John W. Fitts, of Atlanta, reelected secretary 
and treasurer. 

Physicians Needed for European Service. — 
The American Red Cross Society announces that 
the services of a number of medical men are needed 
among the children of Eastern Europe. It is said 
that the service is particularly suitable for recent 
graduates. The remuneration will be sufficient to 
represent an adequate salary and living expenses. 
The need is urgent, and all who are interested in 
this work are asked to communicate at once with 
Dr. Charles W. Berry, 44 East Twenty-third Street, 
New York. 

Tri-State Medical Society. — The sixteenth an- 
nual meeting of the Tri-State Medical Society of 
Arkansas, Louisiana and Texas, was held recently 
at Texarkana, Texas. The following officers were 
elected : President, Dr. Frank H. Walke, of Shreve- 
port. La. ; vice-presidents, Dr. Leonce J. Kosminsky, 
of Texarkana, Ark., Dr. Spencer A. Collom, of 
Texarkana, Texas, and Dr. John A. Hendrick, of 
Shreveport, La. ; secretary. Dr. Netrie Klein, of 
Texarkana, Texas. Shreveport, La., was chosen as 
the place for the 1921 meeting. 

Infant Death Rate Falls in Great Britain. — The 
aimual report for 1919 of the Registrar General for 
England and Wales shows fewer deaths now occur- 
ring in childhood. Death rates by far the lowest 
on record are shown for 1919 from measles and 
whooping cough, while the low death rate from 
diarrhea has only once been bettered. The death 
rate at most ages of life shows a tendency to decline, 
except in the case of cancer. The excess of infant 
deaths in London over the average for the country 
which was noted as an exceptional feature of the 
1917 and 1918 figures has disappeared. 

Certified Water. — Within the last twelve 
months the danger to railway travelers of infection 
with typhoid fever, dysentery, and other water borne 
diseases has been reduced to a minimum throughout 
the greater part of the country by the cooperation 
of the U. S. Public Health Service with the dif- 
ferent state boards of health in the testing of the 
water used on railway trains for drinking and 
cooking. Within the next few months, similar 
protection will be afforded to passengers on river 
and lake steamers and to ocean steamships sailing 
from American ports. This will tend to end the 
severe outbreaks of typhoid fever that have from 
time to time been traced to ships (especially to 
excursion boats), as well as to the probably more 
numerous but far less easily traced illnesses of rail- 
way travelers from similar pollution. 



January 8, 1921.] 



NEWS ITEMS. 



77 



Vital Statistics of New York. — During the 
fifty-two weeks of the year 1920 there were 72,874 
deaths, corresponding to a rate of 11.90 in a thou- 
sand of population, compared with a total of 74,419 
deaths and a rate of 12.39 in a thousand of popula- 
tion last year. During this period 11,279 infants 
died, a rate of 85 in a thousand births. During 
the corresponding period last year 10,639 infants 
died, a rate of 83 to a thousand births. 

Demonstration of Radium Treatment of Can- 
cer. — Under the auspices of the Health Depart- 
ment of the City of New York, a series of lectures 
will be delivered in New York during the month 
of January to emphasize the curability of many 
forms of cancer in the early stages by radium 
therapy. The object, as explained by Dr. Royal S. 
Copeland, health commissioner, is to allay the fear 
of surgery which, he believes, deters many persons 
from seeking treatment while the disease is in the 
incipient stage. It is announced that a radium ex- 
pert will assist in the lectures, exhibiting some of 
the methods of radium therapy. 

Surgeon Directs Operation by Wireless. — Dr. 
Patrick S. Burns, of Providence, R. I., chief surgeon 
on the Leyland liner Winifrcdian, directed by wire- 
less the setting of broken bones and the care of > 
internal injuries sustained by seamen on the Belgian 
steamship Mcnapier when that ship was battered 
by a hurricane. When an S. O. S. message from 
the Belgian steamship brought the Winifrcdian to 
her assistance, Dr. Burns attempted to put out 
in a life boat, but was prevented by the storm, so 
by wireless he directed the method of treatment in 
each case. The two ships lay alongside each other 
for three days, but the storm prevented any com- 
munication other than by wireless. At the end of 
that time the men were all reported as out of danger. 

Resolutions on Death of Dr. Meltzer. — At 
a special meeting of the council for the New York 
Society for Thoracic Surgery, the following reso- 
lutions were adopted upon the death of Dr. Samuel 
J. Meltzer: 

Whereas, On November 7, 1920, death removed from the 
roll of this society our distinguished colleague, Dr. Samuel 
J. Meltzer ; and 

_ Whereas, During his membership in this young associa- 
tion Dr. Meltzer has been an active worker and an ardent 
and enthusiastic supporter of the objects which called the 
society into being; and 

Whereas, By his formal communications as well as by 
his illuminating discussions, in fact by his mere presence, 
he has been a continuous source of inspiration to its mem- 
bers; and 

Whereas, His important discovery of overcoming the 
dangers of acute operative collapse of the lung by means of 
his world renowned "Intratracheal Insufflation" is an epoch 
making contribution to thoracic surgery; and 

Whereas, Doctor Meltzer was honored with the office of 
first president of the American Association for Thoracic 
Surgery, the offspring of this society; therefore, be it 
Resolved, That in the death of our colleague the New 
-York Society for Thoracic Surgery has lost one of its most 
valued and beloved fellows ; and be it further 

Resolved, That these resolutions be spread upon the 
records of this society and a copy be forwarded to his be- 
reaved family and to the medfcal journals. 

Howard Lilienthal, M. D. 
Willy Meyer, M. D., 
William H. Luckett, M. D. 
Carl Eggers, M. D., Secretary. 



Motor Accidents in Chicago. — The total num- 
ber of deaths in Chicago resulting from automobile 
accidents in the year 1920 is placed by Coroner 
Peter M. Hoffman at 559. That figure represents 
an increase of approximately twenty-five per cent, 
over the automobile deaths of 1919. In 1919, 
420 persons met death in motor crashes. In 1918 
the number of fatalities resulting from automobile 
accidents was 374. In the year just passed 5,757 
coroner's cases were presented to Mr. Hoffman. 
Of that number physicians issued 2,144 death cer- 
tificates. The remaining 3,613 cases required coro- 
ner's inquests, and one seventh of them were auto- 
mobile deaths. 

Meetings of Local Medical Societies. — During 
the coming week the following medical societies 
will meet in New York: 

Monday, January loth. — Society of Medical Jurispru- 
dence; New York Ophthalmological Society (annual); 
Yorkville Medical Society ; Association of Alumni of St. 
Mary's Hospital, Brooklyn ; Williamsburg Medical Society. 

Tuesday, January iith. — New York Academy of Medi- 
cine (Section in Neurology and Psychiatry) ; Manhattan 
Dermatological Society; New York Obstetrical Society; 
Clinical Society of the Hospital and Dispensary for De- 
formities and Joint Diseases. 

Wednesday, January I2th. — Medical Society of the Bor- 
ough of the Bronx (annual) ; New York Pathological So- 
ciety ; New York Surgical Society ; Alumni Association of 
Norwegian Hospital ; Brooklyn Medical Association. 

Thursday, January 13th.- — New York Academy of Medi- 
cine (Section in Pediatrics); West End Clinical Society; 
Brooklyn Pathological Society. 

Friday, January J4th. — New York Academy of Medicine 
(Section in Otology) ; Eastern Medical Society of the City 
of New York; Flatbush Medical Society; Society of Ex- 
terns of the German Hospital in Brooklyn. 

€> 

Died. 

Baxter. — In Somersworth, N. H., on Monday, December 
27th, Dr. Hemon Baxter, aged eighty-eight years. 

Davis. — In Lamanda Park, Ca!., on Thursday, December 
23rd, Dr. Nathan Smith Davis, of Chicago, 111., aged sixty- 
two years. 

Freeman.— In Philadelphia, Pa., on Monday, December 
20th, Dr. Walter J. Freeman, aged sixty years. 

Grant. — In Lynn, Mass., on Tuesday, December 28th, 
Dr. James H. Grant, aged seventy years. 

Hershm.\n. — In Alliance, Neb., on Monday, December 
20th, Dr. Charles E. Hershman, aged thirty-five years. 

Kimball. — In Boston, Mass., on Tuesday, December 28th, 
Dr. Samuel A. Kimball, aged sixty-three years. 

De Kraft. — In Greenwich, Conn., on Friday, December 
24th, Dr. Sarah L. De Kraft, aged eighty-seven years. 

KuNKEL. — In Salamanca, N. J., on Saturday, December 
18th, Dr. Oscar F. Kunkel, aged forty years. 

LocKRiDGE. — In Ronceverte, W. Va., on Friday, December 
17th. Dr. James P. Lockridge, of Minnehaha Springs, 
W. Va., aged fifty-eight years. 

Mills. — In Missoula, Mont., on Monday, December 6th, 
Dr. William P. Mills, aged sixty-three years. 

McMillan. — In New Egypt, N. J., on Friday, December 
17th, Dr. William T. McMillan, aged fifty-two years. 

O'Brien. — In Ashland, Wis., on Monday, December 20th, 
Dr. William T. O'Brien, aged fifty-nine years. 

P.\GE. — In Bel Air, Md., on Wednesday, December 22nd, 
Dr. Robert S. Page, aged forty-six years. 

Taylor. — In Ridley Park, Pa., on Sunday, December 
26th, Dr. Horace Furness Taylor, aged thirty-nine years. 

Wallace. — In Newport, Wash., on Tuesday, December 
21st, Dr. Walter S. Wallace, aged thirty-seven years. 



Book Reviews 



MANUALS ON DIABETES. 

Patient's Handbook on the Treatment of Diabetes Mellitus. 
By Thomas W. Edgar, M. D., Associate Editor on Dia- 
betes, Western Medical Times ; Author of Psychology 
of Prognosis, Limitation of Starvation in Diabetes, etc. 
Boston: Richard G. Badger, 1920. Pp. 100. 

Diabetes. A Handbook for Physicians and Their Patients. 
By Philip Horowitz, M. D. With Twenty-seven Text 
Illustrations and Two Colored Plates. New York : Paul 
B. Hoeber, 1920. Pp. xii-196. 

Neuvas Orientaciones Sobre la Patogenia y Tratamiento dc 
la Diabetes Insipida. Par Dr. Gregorio ^Iaranon, de 
Hospital General. Madrid : Editorial Saturnino Calleia 
S. A., 1920. Pp. 13, 174. 

Much progress has been made in the treatment 
of diabetes. The manuals reviewed here have been 
written by speciaUsts whose names are familiar to 
the readers of the New York Medical Journal. 
For this reason these books should be of special 
interest to our readers. 

* * * 

Most medical writers take us back to Hippocrates, 
but, in this case, he had nothing to say about dia- 
betes, so the reader of Edgar's book is hurried on 
to a species of mortuary in which 11.775 persons lie 
dead of diabetes (1915), which makes him timor- 
ously inquire what brought them there, what pre- 
disposed them to so grim a fate. No age, no class, 
is exempt, answers the author gloomily. Has 
lovely woman no exemption? Yes, slightly beyond 
the man. Has race any exemption ? The Jews are 
particularly susceptible. Does heredity play any 
part? More in environment and association than 
by being a predisposing factor. Infection? It dis- 
claims any share. Dr. Edgar thinks nervous influ- 
ences a strong detennining factor, also head in- 
juries, typhoid, diphtheria, rheumatism, and some- 
times syphilis. 

Among theories as to the cause, Edgar gives his 
own, saying it is a complication of chronic intestinal 
stasis. The toxins formed in the intestinal track 
due to fermentation and putrefaction of carbo- 
hydrates and proteids in time cause a degeneration 
of the glandular structures with a resultant retarda- 
tion of function causing the body to lose its power 
to care for its sugar content. He considers the 
disease not primarily one of the pancreas but of 
the entire ductless gland system. Other glands than 
the pancreas are concerned in sugar metabolism, 
and when the secretion of one or more is interfered 
with diabetes follows. Sugar in the urine often 
causes needless worry. The amount the patient is 
able to assimilate is the safest indication of severity. 

No drugs figure in Edgar's treatment, but one 
thing will meet favor with some : he believes in 
alcohol when the diet is being reduced as it acts 
as a fat sparer and has direct value as food. Alco- 
hol is ideal in that it is entirely oxidized, leaving 
no byproducts harmful to metabolism. 

For the past year the author has been using a 
serum derived from the blood of rabbits, also an 
infusion derived from a plant which grows in 
Southern Italy in December and January. It is a 
kind of nettle, and its action is to cause oxidation in 
the body and make the sugar disappear. There is 



a graduated series of diet charts which would be 
attractive to any invalid. No bread on the menu, but 
bran cakes, made from stable bran, are permitted. 
A word of warning is given against the deceptive 
appearance of the healthy diabetic who is a whited 
sepulchre despite his ruddy cheeks. Boasting of his 
power to defy dietetic rules and yet preserve health, 
he one day feels drowsy, shortwinded, comatose, and 
heads for the tomb while the doctors sadly sigh, 
"We told you so." From such a fate may common 
sense and Edgar's helpful volume deliver us. 

* * * 

Anyone who has passed an hour or two in the 
consulting room of an internist knows the frequent 
inquiries which come from fussy or disconsolate 
patients over the telephone, particularly from dia- 
betics, imploring permission to eat a little forbidden 
food, or, complaining of pain, and being questioned, 
reluctantly admit that they have eaten to test their 
improved health or because they would not appear 
unsociable. The doctor sees no difference between 
suicide with a lobster salad and bichloride of mer- 
cury, since the effect of each is understood by the 
diabetic. 

Dr. Horowitz, suffering like his confreres from 
unreasonable and disobedient patients, has tried to 
mend matters by taking them into his confidence. 
He has exposed the mechanism of life and the 
causes of disharmony, the reasons for prohibition 
of some foods, the nutritive excellence of others. 
He has given simple tests for sugar which the 
patient himself can make. This will keep a sick 
one interested, for ninety-nine per cent, find their 
own insides a fascinating study. To the normal, 
healthy person who shovels food down in an absent 
minded fashion and thinks calories and vitamines 
are some form of disease, the diet charts seem both 
liberal and varied. Allowance is made for idio- 
syncrasies in food, extra portions are allowed as 
soon as they can safely be taken. One day a week 
is a Green Day, which simply means extra green 
vegetables and is not to be confounded with Arbor 
Day or Irish demonstrations. 

The author, though assured of the value of 
cultures of Bacillus bulgaricus, does not say it is 
as a cure, but says it helps to take care of and neu- 
tralize an existing autotoxemia and increases the 
time necessary for starch to be converted into dex- 
trose or glucose, so that smaller quantities of glucose 
are formed in a given time. Large doses are 
found to produce the best results. 

Diabetes, nephritis, arteriosclerosis, gout, and 
other forms of metabolic disturbance are ascribed 
to a form of autointoxication causing an interference 
with the functions of the ductless glands, or irrita- 
tion of these and other organs. This statement is 
based on personal research and animal experimenta- 
tion and is enlarged on in the book. There are 
excellent tested menus, recipes and analyses of food 
which will help the tired doctor and secure the 
cooperation of the doctored. The section on Juv- 
enile Diabetes will be useful to mothers and nurses 
in the difificult ta.sk of coaxing a child to eat what 



January 8, 1921.] 



HOOK KEl'lEW 



79 



he does not fancy. ' Any diabetic wlio reads the 
clear directions and warnings can no longer plead 
ignorance in provoking symptoms he is unable to 
relieve. 

* * * 

Dr. Maranon has written a very valual)le and 
complete treatise on diabetes insipida, with a bibli- 
ography which pretends to be complete on the 
subject ; inasmuch as the references number one 
hundred and forty-six, this claim to completeness 
seems justified. The essence of the author's views 
on the pathogeny of the disease may be said to be 
found in his conclusions stated at the end of the 
first chapter, namely, "almost absolutely all cases of 
diabetes insipida present symptoms which demon- 
strate the existence of a hypofunctional lesion of 
the middle and posterior lobes of the hypophysis." 

Consequently, his treatment is directed along the 
lines of supplying this deficiency in function of the 
pituitary gland. In this regard he is convinced of 
the inefficaciousness of drugs, restriction of fluids, 
salt free or low nitrogenous diets, hydrotherapy or 
electricity ; however, in those cases which show an 
evident hypertonia of the vagus, belladonna and 
atropine have been partly useful. Pituitary extract 
has been used by Maranon with uniform success, 
administered both hypodermically and by mouth ; 
whether a true cure can be effected remains to be 
seen, although this may be hoped for in a certain 
proportion of cases, always remembering that 
tumors of the hypophysis must be treated surgically. 

HOOKWORM AND MALARIA. 

Hookivorm and Malaria Research in Malaya, Java, and the 
Fiii fslands. Report of the Uncinariasis Commission to 
the Orient, 1915-1917. By S. T. Darling. M. D., M. A. 
Barber, Ph. D.. and H. P. Hacker, M. D. Publication 
Xo. 9. New York : The Rockefeller Foundation Inter- 
national Health Board, 1920. Pp. x-191. 

Parasites have been written about since earliest 
antiquity ; the commonest were known to the 
Egyptians, and we may believe that all early peoples, 
civilized or savage, knew a great deal about them, 
for hygiene as it figured in their religion deals much 
with precautions against them. So, to these men 
the sight of great scientists setting out on a far 
voyage to fight a worm, a fly, an ameba, and, re- 
turning some years after, not wholly victorious, 
W'ould have seemed quite a necessary thing. 

In this report are garnered two years' work, and 
some excellent pictures of the people who regard 
precautions as petty tyranny, and wash themselves, 
their clothes, their rice, in the same water, even 
defecating if convenient. It was not a matter of 
surprise that one place. Batavia, Java, had an inci- 
dence of ninet)'-five and two tenths per cent, with 
average number of worms forty-nine. 

The commission had a heavy , task in examining 
Chinese. Tamils, Fijians, Malays, Indians, and 
others, because the susceptibility varied, the health 
; conditions varied, and certainly ideas varied among 
the people as to the use of worrying. Even the 
! vulnerability of the worms in relation to vermicide 
I varied. Chenopodium was the usual antidote, but 
the Ancylostoma duodenale, a species of which the 
Chinese had the larger proportion, had the mouth 
part larger than the Necator. The anatomical dif- 



ference would enable the former to inflict more 
serious wounds in the mucosa, and cause greater 
anemia and re(iuired higher doses of vermicide. It 
was found well to express the hookworm species 
formula in percentages of ancylostoma, because 
that indicates the necessity of the higher dose. 

Seeing the many variations, it is impossible to 
([uote adequately concerning hookworm and ma- 
laria. The report is so concise, so anxious to in- 
form, that the interested man will hurry to order it. 
The reading raises a doubt as to the real meekness 
of mortal man in calling himself a worm, even a 
vile one, seeing its power to torment and kill, while 
the wicked worm mu.st curl up in laughter at the 
abortive efforts to get rid of him. 

THE INDUSTRIAL CLINIC. 

The Industrial Clinic. A Handbook Dealing witli Health 
in Work. By Several Writers. Edited by Edgar L. 
CoLLis, M. D. (Oxon.), M.R. C. P.; Talbot Professor 
of Preventive Medicine in the University of Wales ; Late 
Director of Welfare and Health, Ministry of Munitions, 
and H. M. Medical Inspector of Factories. Modern 
Clinic Manuals. New York: William Wood & Co., 1920. 
Pp. xii-2.59. 

The "several writers" certainly have done their 
work well, but those with an unthinking mind would 
do well to avoid this volume, be they employers 
or employed, for no one can gain knowledge with- 
out increase of responsibihty ; theirs is then the sin 
of those who know the right and do it not. The 
employer may no longer consider his workpeople 
as hands, or a staff, or a gang or .shift : they are 
men and women with brain and heart, stomach 
and lungs, and emotions, as he himself has. He 
may still continue to engage hands, but those same 
hands, influenced by socialist meetings and poor 
cooking, bad air, and the lack of a tubbing, now 
yield ugly missiles, vocal and instrumental, for 
retaliation when consideration by the employer is 
lacking. 

Doctors, economists, theologians, philanthropists, 
are urging the employer to this duty because of the 
increased output of work it will eventually mean, 
and the gradual, sobbing subsidence of the waves of 
the high sea of revolt. There will also be the .social, 
civic distinction of being a model employer dis- 
countenancing greed and graft, petty tyranny, and 
selfish neglect. 

But he has the uphill task of contending against 
suspicion and ignorance. "Just to get more work 
out of us," growl the people. "Spying on us with 
his blooming tests. The other day old Bill was laid 
off ; too slow, not up to new machinery, and, un- 
knowing, his own young daughter got the job." 
Then, those for whom gloves and masks, spectacles 
and special overalls, are provided, are the very ones 
not to use them. The precautions worry them, and, 
after all. they may not be the next ones to suffer. 

Now, granted that the boss has advertised for. 
selected, and suitably placed the new hand, our 
several writers press around and say he must not 
overwork him ; must give him well ventilated, well 
warmed workrooms ; must eliminate or guard 
against the use or incurrence of things dangerous 
to health ; must provide a medical ofificer, and, where 
possible, a canteen, cloak rooms, adequate toilets; 
The employer has a hard task. Let him be thankful 



80 



BOOK REVIEWS. 



[New 

Medical 



York 
Journal. 



his liabilities do not yet extend as far as suitable 
housing. 

And do these men write only for employers? 
No ; for any who are concerned, voluntarily or 
involuntarily, with the great world of labor. They 
begin with treating the engagement of the worker 
on medical and psychological grounds, then indus- 
trial efificiency, fatigue, environmental and per- 
sonal hygiene, ambulance and first aid work, physi- 
ology, and economy of food supply; finally, the 
employment of women. They ask for chief auditors 
of their book, factory medical officers and welfare 
workers. 

The material has been carefully gathered by well 
known men. Dr. Leonard Hill writes clearly and 
usefully on Food Values in Relation to Occupation. 
All the men were daily using their energies during 
the war, and are not writing merely to make a 
book but to make men. 

THE NERVOUS HOUSEWIFE. 

The Nervous Housewiie. By Abraham Myerson. Bos- 
ton : Little, Brown & Co., 1920. Pp. 273. 

Long ago, B. C, there were bitter complaints 
about women ; living with a scold was like "a per- 
petual dripping on a very rainy day" ; they beguiled 
the hundred per cent, young men from virtue's 
path. They liked walking about Fifth Avenue, 
Jerusalem, in "changeable suits of apparel," mantles, 
hoods and veils, crisping pins, ornaments on their 
legs, chains and bracelets. They were sly and 
subtle Rachaels and Delilahs, liking to mix up with 
politics as did Jezebel and Herodias, or to singing 
Socialist songs, like the Virgin IMary. Curiously, 
the men did not see anything unwomanly in the 
deeds of a Jael or Judith or any such stern minded 
woman. Taking century long strides through the 
ages, we find there were always men who said there 
never was a time like that present,, with women 
so ab-so-lute-ly frivolous and damaging. Roger 
Ascham was doubtful of any good at all in them ; 
Thackeray deluged them with cynicism ; Kipling's 
poem is as bad as Solomon's doleful reproaches, 
and he certainly saw plenty of thetn. That famous 
answer to the query, "Who can find a virtuous 
woman?" ascribed to Solomon, was written by one 
of the Mrs. Solomons, and taught to her son, 
Lemuel. 

Here we are, then, in 1920, with all the world 
whirling more swiftly, with manners and customs 
changed, with no doors closed to the independent 
young women, expecting her to settle down in 
humble flat or maisonette and find full joy in 
domesticities. Even in 1817 she was condemned 
for seeking inky diversion, for Lady Morgan was 
thus addressed in the Morning Post: 

Lady, lay down the pen ; take up the needle. 

Mend shifts or stockings : darn, a decent sight. 
But, if thou can'st not sew, thrum tweedle-deedlc. 

In short, fair dame, do anything but write. 

There is found in Dr. Myerson's book neither 
condemnation nor mockery, but a sympathetic com- 
prehension of that which makes nervous house- 
wives. One disturbing element is the nonconfluence 
of two ideas : one that marriage implies the depend- 
ence and essential inferiority of woman, the other 



that the man and woman are equal partners in the 
relationship. When this question is settled, the 
home will be reorganized in relation to the new 
belief. It has also to be borne in mind that the 
child, too, has changed. The mother has to deal 
with a more alert, more sophisticated, more sensu- 
ous child, and tots of five years are sent to the 
kindergarten because they wear their mothers out. 
Restricted childbearing is prevailing more and more ; 
had the woinan of the past known how, she also 
would have had fewer children ; but the author 
speaks plainly and wisely on the other side- 
sterility. The chapter on The Nature of Nervous- 
ness will enlighten the young wife who regards 
neurasthenic, neurotic, psychasthenic, hysteric, as 
interchangeable terms. In The Types of House- 
wife Predisposed to Nervousness, the wife may find 
her own picture ; she has plenty to choose from. 
There is the fussy woman, the jealous, the hyper- 
sensitive, the ultrameek inwardly rebellious, the 
nagging, the hysterical, the dreamer. But it is just 
to say that the author deals with these same con- 
ditions as occurring in husbands. Conditions arising 
from original sin or constipation, from too much 
conscience or too much candy, from deadly dullness 
or ainusement saturation, are thoroughly sifted; 
also the more serious one of the lack of passion and 
the quick divorce. 

Every sensible w'oman will take her just share of 
blame as she reads ; every foolish one will demand 
her share of excusation ; every husband will take 
new views of life and his wife. 

^ 

New Publications Received. 



{IVe publish full lists of hooks- received, but we acknowl- 
edge no obligation to review them all. Nevertheless, so 
far as space permits, we review those in which we think 
our readers are likely to be interested.] 



THE SILENT MILL. Bv HERMANN SuDERMANX. New 

York: Brentano's 1920. Pp. 204. 

LAOTZu's TAG and wu WEI. Translated by Dwicht God- 
DARD. New York: Brentano's, 1920. Pp. 116. 

THE STORY OF A STYLE. By WiLLIAM BaYARD HaLE. 

New York : B. W. Huebsch, Inc., 1920. Pp. 303. 

bergson and personal REALISM. By Ralph Tyler 
Flewelling, Professor of Philosophy in the University of 
Southern California. New York, Cincinnati : The Abing- 
don Press, 1920. Pp. 304. 

praktikum der klinischen chemischen, mikroskop- 
ischen und bakteriologischen untersuchungsme- 
THODEN. Von Dr. M. Klopstock, San-Rat, und Dr. A. 
Kowarsky in Berlin. Sechste, umgearbeitete und ver- 
mehrte Auflage. Mit 40 Textabbildungen und 24 farbigen 
Tafeln. Berlin, Wien : Urban & Schwarzenberg, 1920. 
Seiten, xv-518. 

common infections of the kidneys with the colon 
BACILLUS AND ALLIED BACTERIA. Based on a Course of 
Lectures Delivered at the London Hospital. By Frank 
KiDD, M.B., B.C. (Cantab.), F.R.C.S. Eng., Surgeon of 
London Hospital ; Surgeon-in-Charge of Genitourinar\- 
Department, London Hospital ; Member of the International 
Society of Urology, etc. With an Additional Lecture on 
the Bacteriology of the Urine by Dr. Philip Panton, Clini- 
cal Pathologist, London Hospital. London : Henry 
Frowde (Oxford University Press) and Hodder and 
Stoughton, 1920. Pp. xx-331. 



Practical TTierapeutics and Preventive Medicine 

A Compendium of Treatment and Prophylaxis, Original and Adapted 



Treatment of Tumors of the Female Bladder. 

— William Neill (American Journal of Surgery, 
December, 1920) states that the method of treat- 
ment during the past five years has drawn further 
and further away from any operative procedure, 
except in the cases of massive tumors. The treat- 
ments can be given with great ease and accuracy 
through the Kelly cystoscope. The best results have 
been obtained by the use of radium. The flat 
tumors with broad sessile bases are treated by 
implanting (or shooting) directly into the tumor, 
tiny capillary glass tubes containing from three to 
five ma. of the radium emanation, which are left 
permanently, and which give a tremendous radia- 
tion throughout a long period. From one to several 
of these spicules may be implanted, depending on 
the size of the growth. This form of treatment 
should never be repeated under four to six weeks. 
In association with this method and also for the 
smaller definitely pedunculated tumors the emana- 
tion attached to a sound and encased in a brass or 
platinum capsule is used, which is held directly on 
the tumor. For this the equivalent of one gram 
of radium in the form of emanation and on an 
average of from five to ten minutes on each existing 
tumor is used. ' Such cases are ambulatory or ofiice 
patients and are examined and treated on an average 
of once a week for from four to five weeks. At 
the end of that period all treatments are discon- 
tinued and the patient allowed to go off for six 
weeks. Then another examination is made and the 
treatments again instituted, depending on the 
amount of trouble remaining. With this method 
of treatment, instead of putting the patients to. bed 
and exposing them to the risks and discomforts of 
an operation, they are handled simply as office cases, 
and in the meantime they lead their regular lives at 
home. Patients are never discharged as cured, but 
even after the last vestige of trouble has disappeared 
they are instructed to report at regular intervals for 
examination. The tendency to recurrence is so 
great that in this way the recurrence is treated as 
soon as it becomes evident. 

Treatment of Persistent Bone Sinuses. — 
Charles William Peabody (Surgery, Gynecology 
and Obstetrics, November, 1920) states that in the 
year following the armistice about five hundred 
cases of bone sinuses following gunshot wounds 
came under observation for varying periods of time. 
These had presented an unusually stubborn surgical 
problem and in spite of prolonged surgical treatment 
litde progress was being made toward a cure. From 
treatment of about half of these a procedure was 
evolved which led to the clinical cure of the great 
majority. It was found that the presence of an 
infected bony cavity was the essential cause; that 
a revision operation sufficiently radical entirely to 
eliminate this faulty configuration was the first step 
required; that the concomitant infection could be 
effectively controlled and terminated in a compara- 
tively brief time by careful wound treatment based 



on physiological and antiseptic grounds. It thereby 
became possible, as well as desirable from the func- 
tional viewpoint, to close these wounds by a bold 
reconstruction operation. 

Persistent bone sinuses are a very common and 
a very serious complication of gunshot wounds 
producing compound, comminuted fractures, unusu- 
ally resistant to ordinary surgical treatment. A 
system of operative and postoperative procedure 
directed against the underlying etiological factors 
has been devised after considerable experience 
which in a high percentage produces a clinical cure. 
Such a method must stand the further test of late 
results before it can be regarded as the means of 
permanent cure in every case. 

Treatment of Stricture. — A. Ravogli (American 
Journal of Surgery, December, 1920) states that 
the treatment of urethral stricture has for its aim the 
enlargement of the lumen of the urethra and main- 
taining its enlarged calibre by dilatation. Dilatation 
is effected gradually and gently by the use of sounds, 
which, massaging the scar tissue of the urethra, 
causes its absorption. The maximum of effect should 
be produced by the minimum of effort, for the effect 
is due not to the pressure of the sound, but to its 
mere contact. Passing a sound by force, will tear 
and bruise the mucous membrane and consequently 
increase the inflammatory reaction. A steel sound 
must go in without effort. In this way the presence 
of the sound will be able to lessen the congestion 
at the point of contact, correct the irregularities in 
the canal and stimulate the deeper tissues to a reac- 
tion so as to soften the cicatrix. The method of 
forced dilatation and of divulsion, which some years 
ago were largely applied with serious consequences, 
have been abandoned. When the stricture is yet 
soft or in a semifibrous stage, it can be easily re- 
moved by prompting the reabsorption of the 
infiltrated elements by means of gradual dilatation. 

Treatment of Urethral Stricture. — Edgar G. 
Ballenger and Omar F. Elder (American Journal 
of Surgery, December, 1920) state that the best 
method of treatment is by gradual dilatation with 
sounds and the Kollmann dilator until the urethra 
has been dilated to a size considerably larger than 
normal in order to allow for the contraction that 
will follow later. The dilatations may be given with 
intervals of one to five days according to the reac- 
tion which follows. As a rule, the urethra should 
not be dilated again until the irritation of the previ- 
ous treatment has subsided. The dilatation should 
be gradual, because overdilatation at any one time 
is undesirable for the obvious reason that if the 
damage to the constriction is gross or massive, it 
will be repaired by scar tissue and the stricture will 
ultimately be made worse. The object in dilating 
the constriction is to cause a necrosis of the most 
constricting fibres by damage so slight that it will 
not be repaired by scar tissue but will undergo 
absorption, thereby lessening the constriction. It 
may become necessary or advisable to perform an 



82 I'RACriCAL THERAPEUTICS AND TREl'ENTIl'E MEDICINE. INew Yokk 

lEDicAL Journal. 



internal urethrotomy which is the phm to follow in 
incising strictures in the anterior urethra. Too 
much hemorrhage is likely to follow if this opera- 
tion is done in the deej) urethra, the external 
perineal urethrotomy is the operation of choice in 
this region. The following are some of the reasons 
for incising uretliral strictures ; resilient ones which 
(juickly recontract after dilatations ; those which for 
other reasons do not respond in a reasonable time 
to adequate dilatations ; strictures too extensive or 
too tight for gradual dilatation ; and occasionally 
where the patient lives in a 'place too remote from 
a surgeon to employ the dilating method. 

External perineal urethrotomy is indicated in 
tight or resilient strictures of the deeper part of the 
urethra, that is, in the region near the external 
sphincter ; furthermore, this operation is required 
where there is complete or nearly complete ob- 
strtiction of the urine; for infiltration of urine and 
where there is stone in the bladder complicating the 
stricture. It is of great importance to pass an in- 
strument or a filiform through the urethra into the 
bladder to act as a guide in incising the constriction. 
This should be done before the anesthesia is started. 
The perineal incision is made down to the point of 
the instrument in the deep urethra, then a probe 
pointed gorget is passed through the stricture into 
the bladder. When unable to pass an instrument, 
we have recourse to one of two methods. First: 
Bore through the stricture with the forefinger 
until the stricture is passed. Second : Suprapubic 
cystotomy should be performed and the dilated part 
of the urethra back of the stricture found by retro- 
grade sounding. A large catheter is fixed in the 
urethra after external perineal urethotomy and 
allowed to remain in the urethra for ten days. The 
bladder is irrigated daily through the catheter with 
a saturated solution of boric acid. Subsequent 
dilatation should be followed as in dealing with 
ordinary dilatable strictures. 

Treatment of Ruptured Urethra. — J. Richard 
Allison {Military Sttrrjcon. September, 1920) con- 
cludes as follows : 

1. When the diagnosis of rupture of the urethra 
has been made whether complicated by fracture of 
the pelvis, ruptured bladder or what not, a perineal 
section should be done immediately. 

2. A suprapubic operation should not be done 
unless it has been found by examination that the 
bladder wall is ruptured and then only for rejjair 
of the bladder wall. 

3. A suprapubic operation should not be done 
merely for retrograde catheterization until the 
operator has failed after diligent search to find the 
proximal end of the urethra. 

4. The torn ends of the urethra should be sutured 
with as good anatomical approximation as possible. 

5. The catheter should be left in the urethra until 
the wound is healed sufficiently to prevent a peri- 
neal fistula. 

6. The aftercare should always be considered the 
important point in obtaining good results. 

7. Sounds should be passed two or three days 
after the catheter is removed, and then at intervals 
for a long period depending upon the nature of the 
stricture. 



Treatment of Suppurative Cystitis. — ^Augustus 
V. Wendel {/Imcriccm Journal of Surgery, Decem- 
ber, 1920) asserts that the most important elements 
in the treatment of purulent cystitis are to keep the 
bladder continuously clean and to improve the 
nutrition of the local tissues. The vesical membrane 
being more or less ulcerated and covered witli 
firmly adherent mucopurulent masses, often incrus- 
tations, the futility of irrigations, as ordinarily 
administered, becomes evident. Such bladders are 
therefore cauterized with solid silver nitrate, ful- 
gurated and burned with the actual cautery 
practically through the whole thickness of the blad- 
der wall, but very few are cured because such 
etTorts are circumscribed. 

Treatment of Wounds of Knee Joint. — W. R. 

Owen (American Journal of Surgery, August, 
1920) gives the following conclusions in regard to 
the Willems method of treatment: 1. All surgical 
methods of draining the knee joint in suppurative 
arthritis have certain drawbacks. 2. The Willems 
method in suppurative arthritis produces free drain- 
age of pus, promotes circulation of synovial fluid 
with maximum power of resistance, and stimulates 
blood supply to the joint. 3. The practical require- 
ments of treatment are: a, free drainage, and. 1). 
active movement. 4. Reports have shown that in 
about fifty per cent, of the cases treated a useful 
mobile joint has been obtained. 5. The Willems 
method should not be employed if delayed until the 
fulminating stage has been reached. 

Treatment of Old Hip Dislocations by Reduc- 
tion. — J. J. Buchanan (Surgery, Gynecology and 
Obstetrics, November, 1920) states that: 1. Trau- 
matic hip dislocations may be considered old at the 
end of four weeks. 2. Reduction by manipulation 
is rarely successful after that time, owing to forma- 
tion of connective tissue, which fills the acetabulum 
and' binds down the head and neck. 3. Reduction 
by open incision is to be preferred in nearly all cases 
of old hip luxations and with modern methods is 
attended with but little danger. 4. Preliminary 
traction by Buck's extension is of advantage. 5. 
The actual replacement of the head, after the 
acetabulum has been emptied and the head and neck 
released, is best accomplished by manipulation or 
the use of levers with manual and body traction. 
6. The result is often ideal and, in the cases reported, 
has been good in eighty per cent. 

Management of Foot Abnormalities. — Tom S. 

Mebane (Military Surgeon, October. 1920) states 
that from the experience gained in dealing with 
large numbers of men in the Army camps, the fol- 
lowing conclusions may be drawn : A foot may be 
considered normal when there is unrestricted joint 
motion and the line of weight bearing passes through 
the fore foot. Foot trouble can be prevented by 
wearing proper shoes, by correcting faulty attitudes, 
I)y care to prevent overtaxing, by eliminating focal 
infections and by the use of exercises to strengthen 
the foot muscles. Symptoms referred to the feet 
are encountered in many conditions. The cure of 
static foot defects is dependent upon muscle 
training. Mechanical correction is to be regarded 
only as an aid to treatment. 



January 8, 1921] PRACTICAL THERAPEUTICS AND PREVENTIVE MEDICINE. 



83 



Treatment of Wrist Injuries. — Mauchet and 
Mauchet {American Journal of Surgery. August, 
1920) state that retrolunar luxation of the carpus 
demands reduction, hke all other dislocations, even 
when associated with fracture of a carpal bone, or 
nerve lesions. The only possible danger in reduc- 
tion exists in those cases where the semilunar is 
dislocated 90°, or where the lesion has existed for 
more than a month. But even if intervention is 
delayed for more than a month, reduction is feasible 
and effectual. It should be done under general 
anesthesia. The surgeon should grasp the hand of 
the patient firmly, and exert traction in the direction 
of the axis of the forearm, at the same time moving 
the wrist slightly so as to make it supple. The hand 
is then brought into dorsal flexion, while traction is 
maintained and inclined slightly to the ulnar side. 
At the same time, pressure is exerted gently with 
the thumb over the palmar surface of the semilunar. 
Finally, the surgeon moves the hand quickly from 
dorsal to palmar flexion. During this manipulation 
the semilunar may be felt slipping into place. This 
is followed by immobilization for four or five days, 
hot baths, hot air, gentle and slow mobilization. In 
case the semilunar is fractured, or the condition 
has lasted more than one month, reduction should 
not be attempted ; the semilunar should be removed 
under local anesthesia, with the superior fragment 
of the scaphoid, if fractured. The incision is made 
on the palmar surface just within the palmaris 
longus. 

Infective Neuronitis. — Foster Kennedy {Ar- 
chives of Neurology and Psychiatry, December, 
1919) observed several cases having many of the 
recognizable symptoms of acute polyneuritis, that 
presented unmistakable evidences of involvement of 
the spinal roots and of the central nervous system 
as well. In some of the earlier cases the main 
incidences of the disease fell peripherally, with 
occasional signs of root involvement, produced 
probably by ascending lymphogenous extension. One 
case emphasized the necessity of including more 
than the peripheral change in the conception held 
of the condition as a morbid entity. A study of 
the sections revealed a patchy neuritis in the peri- 
pheral nerves, and a degeneration of the cells in 
the ventral and dorsal cornua, and especially in the 
cells of the posterior ganglions. Similar but more 
benign changes were found in the deeper layers of 
the cerebral cortex and in the cells of the pontine 
nuclei. A small round cell infiltration was found 
around the ganglion and cornual cells, but never 
around the meningeal vessels as is usual in polio- 
myelitis. The ependyma of the spinal central canal 
showed constant extensive proliferation. The men- 
inges were nonnal. Small quantities of an emulsion 
of the affected spinal cord preserved in glycerine 
injected into monkeys subdurally produced the dis- 
ease clinically after an incubation period of from 
five to seven weeks, and histological examination 
of the nervous tissue of these animals revealed the 
same conditions as found in man. The disease was 
further produced by inoculations from monkey to. 
monkey. Nervous tissue from fatal cases and also 
from monkeys affected with the disease were in- 
vestigated bacteriologically and positive results were 



secured. Minute rounded bodies were found which 
were arranged irregularly or in pairs. This or- 
ganism inoculated subdurally in the monkey repro- 
duced the disease clinically and pathologically, and 
was recovered later from the cerebral cortex, a con- 
sideration that gave emphasis to the present con- 
tention that the problem was one of a widespread 
neuronic infection. 

The Value of Large Single Doses of Digitalis 
in the Treatment of Heart Disease.— G. Canby 
Robinson {Southern Medical Journal, June, 1920) 
advocates the administration of the tincture of 
digitalis in large single doses as a useful method 
of treatment in certain cases of heart disease, pro- 
vided the tincture is standardized, the dose regulated, 
and the patient kept under close observation. This 
method not only brings the heart rapidly under 
the influence of the drug, but also affords a more 
accurate means of studying its effect than the older 
methods of small repeated doses. The use of large 
single doses is apparently not dangerous under 
specified conditions. Problems of the relation of 
dose to body weight still need solution. The bene- 
ficial effect of digitalis in cases with cardiac ir- 
regularity caused by auricular fibrillation is espe- 
cially emphasized by experience with large single 
doses in this condition. 

Blood Transfusion. — E. R. Arn '{Ohio State 
Medical Journal, August, 1920) concludes that salt 
solution will not raise the blood pressure the second 
time. Transfusion of blood alone will save thr 
patient. The citrate method is the method of choice, 
because of the ease of application and preservation 
of important blood vessels for future transfusions 
or other intravenous therapy, should occasion re- 
quire. Transfusion is a specific for hemorrhage in 
the newborn. In hemorrhagic diseases it will re- 
place blood loss, stop the hemorrhage, but not cure 
the condition. Transfusion saves delay and de- 
creases mortality in cases with secondary anemia 
requiring operation, such as fibroid tumors and 
jaundice. Transfusion of blood opens a new field 
of therapy in the treatment of chronic infections. 
Most reactions can be averted by making correct 
group tests and transfusing from the same group 
except in extreme emergencies. 

Diagnostic Significance of Inspiratory Move- 
ments of the Costal Margins. — C. F. Hoover 

{American Journal of the Medical Sciences, May, 
1920) says that in interpreting the inspiratory move- 
ments of the costal margins one must study the 
symmetry and asymmetry not only of the entire 
costal margins, but of the inner and outer portions 
of each costal margin. Movements of these mar- 
gins are modified with changes in the curve of the 
plane of the diaphragm, by paresis of either the 
diaphragm or the intercostal muscles, and by 
synechia between the diaphgram and the ,thoracic 
wall. Such studies improve the accuracy with 
which one differentiates between infraphrenic and 
supraphrenic disease, and enable one also to esti- 
mate the conformation of the heart and the size 
of the pericardial sac, and to differentiate between 
lesions which cause phrenic displacement and those 
which do not modify the plane of the diaphragm. 



Proceedings of National and Local Societies 



AMERICAN PEDIATRIC SOCIETY. 

Thirty-second Annual Meeting, Held in Highland 
Park, III., May 31, June 1 and 2, 1920. 

The President, Dr. Thomas S. Southworth, of New York, 
in the Chair. 

(Continued from page 44.) 
Blood Findings in a Child Five Years After 
Splenectomy. — Dr. Howard Childs Carpenter, 
of Philadelphia, presented in detail the average 
results of thirteen blood examinations in a white 
boy, ten years of age, who had had his spleen 
removed five years Ijefore for familial hemolytic 
icterus of the Chaufifard-Minowski type. The re- 
sult of the operation was satisfactory, and the case 
was reported in the literature a few months later. 
The child's present condition showed him to be an 
active, intelligent child of nervous temperament, 
with good muscular development and scant adipose 
tissue. He was six pounds under weight for his 
height and age, had a faint mitral regurgitant mur- 
mur, with no demonstrable hypertrophy. The thy- 
roid was not enlarged, and there was no jaundice 
or ascites. The external lymphatic glands were 
moderately enlarged. The tonsils were enormously 
hypertrophied. The average of the thirteen blood 
examinations made during the last six weeks 
showed hemoglobin eighty-two per cent., red cells 
4,288,000, and white cells 15,000. No Howell- 
Jolly bodies were found. Prior to operation the 
hemoglobin was as low as twenty-three per cent., 
and the red cells were down to 2,020,000. There 
was still present evidence of bone marrow regenera- 
tion, as .shown by the high color index, the con- 
tinued leucocytosis, moderate chromatophilia and 
poikilocytosis, high transitional and eosinophile 
counts, and finally reticulation of the erythrocytes. 
There was an unusually quick coagulation time in 
.spite of a rather low platelet count, indicating in 
this case either a rapid availability of the platelets 
for the purposes of coagulation or an increased 
amount of prothrombin in the platelets, or a large 
percentage of macroplatelets. The low platelet 
count was simply the continuation of the condition 
which undoubtedly existed before the splenectomy, 
as it was well known that cases of hemolytic icterus 
showed low normal values, sometimes even less than 
200,000. There was also evidence of lymphatic 
activity shown by absolute lymphocytosis, and by 
the enlargement of the external lymphatic glands 
and tlie very large tonsils. 

Food Requirements of Children after the First 

Year. — Dr. L. Emmett Holt, of New York, 
exhibited a number of charts showing the results 
of an attempt to estimate the total caloric needs of 
healthy f children over one year of age. This total 
was determined by the four factors which made it 
up, namely: 1, basal requirements; 2, needs for 
growth ; 3, needs for activity ; 4, loss by excreta. 
For basal needs the curve of Benedict and Talbot 
had been adopted. The per kilo requirement dimin- 
ished steadily from one year to the completion of 
growth. Growth needs were calculated frorri the 



rate of increase in height and weight for the dif- 
ferent years ; these would naturally be greatest at 
periods when growth was most rapid. The loss in 
excreta at all ages was practically ten per cent, of 
the calories taken. These three factors, though sub- 
ject to individual variation with different children, 
were as averages uniform and irreducible. The 
only factor which differed greatly with different 
children was the needs for activity. A child with 
average- activity used up nearly one half his caloric 
intake in this manner ; the very active child much 
more than this. The total caloric needs for the 
average child were greatest during the period of 
most active growth ; in boys, fifteen to seventeen 
years; in girls, thirteen to fifteen years. At this 
period their needs exceeded those of adults with 
moderate activity of both sexes. The adolescent 
boy required four thousand calories daily. The 
average per kilo needs for boys was one hundred 
calories at one year; this gradually fell to eighty 
at six years ; it was then practically constant to six- 
teen years, when it gradually fell to the adult 
average at nineteen years. In general, a little more 
fat, a little more protein, and a little less carbo- 
hydrate were required by the child than by the adult. 

The Effort Syndrome in Children and Young 
Adults. — Dr. Charles Gilmore Kerley, of New 
York, stated that during the late international war 
English army surgeons learned that when certain 
recruits were put to prolonged hard work at drills, 
hikes, and other hard exertion, they failed to 
mea.sure up to the endurance .standard required of 
the soldier in the field. To this condition Dr. 
Thomas Lewis applied the term effort syndrome. 
The condition was described by Friedlander and 
Freyhof as constitutional neurocirculatory asthenia. 
The boy or girl who might qualify for the effort 
syndrome class came to the physician with the 
typical story, which, condensed, meant that there 
was an absence of capacity for sustained effort, both 
mental and physical. Wherever endurance was re- 
quired he failed. In girls these constitutional 
peculiarities might attract less attention and be more 
readily excused when present. Among animals, 
those of defective capacity for economic reasons 
usually had a short career. The defective function- 
ing human, however, if well born, was urged and 
forced and stimulated to accomplish what was not 
in him. Millions of dollars were wasted on youths 
who were physically and mentally unable to meet 
the standard set up by ambitious parents and friends 
in an effort toward their socalled higher education. 
The highly trained teaching talent of our preparatory 
schools and universities was wasted in part on poor 
student material, twenty-five to fifty per cent, of 
which should be scrapped and put to productive 
occupation. Before a boy was permitted to avail 
nimself of unusual educational advantages it .should 
be determined that he was worth it. The high 
school should serve as a clearing house. In addi- 
tion to mental attainments recjuired for college 
entrance it should be required that a candidate sub- 
mit testimonials as to physical fitness and mental 



January 8, 1921.] 



PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES. 



85 



capabilities from the head master or high school 
principal. What was aeeded was expert occupa- 
tional diagnosticians who would aid in placing the 
boys at work for which they were fitted. The boy 
who belonged to the class under discussion should 
leave school at the age of fifteen or sixteen years 
and take up business. In order to make a reason- 
able success the occupation should be one which was 
not strenuous. It was unusual to find persons of 
this type the ofifspring of strong, vigorous young 
persons. In the majority of instances they were 
the offspring of the weakly woman of little resist- 
ance and of lessened endurance capacity. A strong, 
vigorous mother would do much to offset the influ- 
ence on progeny of a weakly male. The progeny 
of vigorous males was greatly reduced by inferior 
mothers. Frequent childbearing had apparently 
been a factor in some instances. The necessity for 
a great deal of attention to the physical development 
of those who would some day be mothers was a 
very urgent need. 

Further Development of Infants' Hospital. — 

Dr. Henry I. Bowditch, of Boston, said the 
present day tendency among hospitals was to de- 
velop the scientific side and its laboratories so as 
to bring them closer to the clinics. This valuable 
information must be properly weighed to be of true 
service, for we were deaHng with the delicate human 
body and mind and not with test tubes, and common 
sense and experience played an important role. 

This idea was being exemplified in the "On 
Shore" Department of the Boston Floating Hos- 
pital, which was being worked out on the basis of 
a ten bed clinic. This new development had been 
made possible by the generosity of a few friends, 
which had permitted the purchase of three small 
adjoining apartment houses which he had had re- 
modelled. The building and equipment had cost 
$45,000. . Ten was felt to be the best number of 
patients, as they could be more readily followed 
clinically, scientifically, and socially. This clinic was 
held in two wards and the necessary isolation room, 
under the expert care of three nurses. The wards 
were so divided that there was less noise and the 
children were able to have perfect naps, morning 
and afternoon ; symptoms dependent upon restless- 
ness, vomiting, etc., were markedly decreased 
thereby. The clinic was so manipulated as to give 
five new patients monthly. The scientific labora- 
tories, chemical and bacteriological, were brought 
into close proximity, making consultation easy, but 
carefully separated so that noises, natural odors, 
etc., did not penetrate. On Tuesday afternoon of 
each week a health clinic, composed of 150 famiHes, 
was held under the guidance of an assistant visiting 
physician. On Wednesday the return "family con- 
trol" clinic was held, in charge of a visiting phy- 
sician. Two clinics were held for weighing the 
children, getting clinical histories and giving treat- 
ment. 

Since opening on December 15, 1919, thirty 
cases had been received, twenty-three of which 
were diagnosed as regulation of feeding and mal- 
nutrition in different degrees. It was the plan to 
admit only nutritional cases, infection being care- 
fully guarded against. The study so far had been 



to organize methods of attacking the question of the 
different food elements in growth and lack of 
growth. Each case was to be examined completely, 
clinically, chemically, and bacteriologically. The 
plan was to have patients return at definite periods 
for chemical and bacteriological tests, physical and 
mental examination, for ten years. In this way 
they followed the development of body and mind. 
A weekly clinic to meet the parents had proved 
satisfactory, allowing personal touch to impress the 
parents with the miportance of physical care, proper 
dietetics and discipline. In time groups of i)arents, 
developing along natural lines, would be formed. 
In this way they hoped to understand the mental 
capacity of the parental group and adapt their 
ideas to their particular peculiarities ; thus compre- 
hending the good points of diet, life, etc., of the 
different races, they hoped to lead them to a better 
understanding of child life. It was hoped that this 
beginning might lead others to establish similar 
"small enough" institutions for the same study 
and for the protection of their medical work. They 
were under the management of the Boston Floating 
Hospital trustees, who considered it a good ten 
years' experiment. They would get perhaps sixty 
patients a year, which at the end of ten years would 
mean six hundred, and then they would be in a 
position to talk of their results. 

The Misuse of Milk in the Diets of Infants and 
Young Children. — Dr. B. Raymond Hoorler, of 
Detroit, stated that the value of milk as a food l)Oth 
for adults and children had been exploited during 
the past few years to such an extent that its use 
was being much increased. This had inevitably led 
to many dietetic errors, particularly in the group 
of children between the ages of one and six years. 
These errors might be classified under the headings : 
1. Prolonged use of milk as an exclusive article of 
diet. 2. Increased quantities of milk given along 
with other foods. Milk might not only be used too 
long as an exclusive article of diet and in excessive 
quantities with other foods, but its nutritional value 
might be injured by boiling. The laity were taught, 
and rightly so, that milk was an ideal breeding 
place for germs, and that the growth of these germs 
might be inhibited by keeping the milk on ice or the 
milk might be brought to a boil and then covered. 
Through this teaching the printed instructions 
accompanying certain patent baby foods, he believed, 
the use of boiled milk was becoming more prevalent 
and many injuries to nutrition occurred. 

Doctor Hoobler exhibited charts showing the diets 
usually given between nine and twelve months, be- 
tween one and two years, and between three and 
five years, and the relative proportion of the day's 
calories supplied by milk when one quart was fed; 
viz., eighty per cent, between nine and twelve 
months; fifty-eight per cent, between one and two 
years, and fifty per cent, between three and five 
years. The relative proportion of different food 
elements which was fed when one quart of milk 
was ingested with other foods was also shown, the 
fat proportion being relatively high and the carbo- 
hydrate relatively low. The amount of overfeeding 
above the basal metabolism which took place when 
one quart of milk was fed was also shown. Often 



86 



PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES. 



[New 
Medical 



York 
Journal. 



the child would refuse spoon feeding and take only 
milk, thus making a bad matter worse, since this 
habit robbed the child of minerals which should 
come to it in fresh fruits, vegetables and cereals, not 
to mention the vitamine and antiscorbutic properties 
which these foods possessed. 

A second chart showed the caloric value and pro- 
portion of food elements when one pint of milk 
daily was fed in addition to other foods, the amount 
given being the same as in the first chart. This 
chart showed the total calories reduced to within 
normal requirements, the proportion of fat and 
carbohydrate being nearly interchangeable, thus giv- 
ing the child ample calories to use up in its activities. 
It also showed lowering of the protein down to the 
maximum for growth, wear and tear. Children 
given such a diet were free from vomiting and 
stupor accompanied by acetonuria so prevalent in 
children who had been fed a quart of milk daily 
in addition to a full diet. The propaganda urging 
the use of a quart of milk daily was fallacious ; when 
followed it led to overfeeding, an unbalanced ration, 
unhealthy nutrition, and frequent attacks of vomit- 
ing accompanied by acetonuria. 

Precipitins for Egg Albumin in Stools. — Dr. 

Clifford G. Grulee stated that the preparation of 
the stools in this series of cases was the same as 
that reported in a previous article. Egg white 
rabbit serum of a titer of 1-40,000 was used. The 
first series tabulated consisted of 100 stools from 
twenty-one cases, with three positive reactions ; in 
both instances the children received egg white in 
the diet. The second series consisted of thirty- 
three cases in which 242 stools gave five positives. 
This series was carried out with an antiserum giv- 
ing precipitants in a dilution of one to 60,000. In 
this group some of the cases giving positive re- 
actions had had no egg albumin in the diet. It 
would seem from these results that egg albumin 
was in nearly every instance completely broken 
down by the digestive processes in infants and chil- 
dren. This held good, not only for children and 
older infants, but also where egg albumin was used 
in small quantities for the newborn as well. There 
was only one other possibility, and that was that 
the egg albumin, instead of being broken down in 
the process of digestion, was absorbed unchanged. 
The writer did not feel that the specificity of the 
precipitin reaction for egg albumin was to any 
degree disproved by the fact that it was found to 
be positive in stools where no egg had been present 
in the diet. He was inclined to attribute such re- 
actions to the complexity of the stool. 

Role of Certain Anaerobes in the Intestinal 
Flora of Infants. — Dr. Langley Porter, of San 
Francisco, said that the information they had been 
able to obtain since their last communication re- 
ferred entirely to the group of intestinal toxemias 
in which the abnormal stool bacteria were resistant 
to dietetic measures usually adequate to produce 
a change in the flora. In the course of this study 
very rarely certain specialized fonns of colon 
bacilli had been encountered. These were highly 
facultative and extremely acid resistant, and so far 
no effective method had been devised for overcom- 



ing their interference when they were present in 
the stools. On the other hand, investigation of the 
evacuations of the majority of patients whose stools 
showed a similar resistance to change in the floral 
balance revealed the presence of an unusual number 
of spore bearing organisms, most often anaerobes, 
usually Welchii, which interfered by virtue of their 
facultative powers. This facultative function en- 
abled them to utilize any pabulum present. Because 
of their power in the active stage to utilize carbo- 
hydrate they were especially likely to interfere when 
any attempt was made to shift a proteolytic flora 
by feeding the patient a high sugar diet. However, 
by the method suggested in this communication this 
interference could be overcome and the disappear- 
ance of these spore bearing organisms from the 
stools insured. A diet limited in protein and rich 
in carbohydrate would efifect this change. 

Experiments to Determine the Persistence of 
Extraneous Bacteria in the Gastrointestinal Tract 
of Guineapigs as Influenced by Diet. — Dr. A. 
Graeme Mitchell, of Philadelphia, stated that 
thus far the proof of the implantation of organisms 
in the intestinal tract rested upon incomplete evi- 
dence. MetchnikofI based his claim of the im- 
plantation of the Bulgarian bacillus upon experi- 
ments carried out by some of his pupils and fol- 
lowers. The work of the later investigators did 
not substantiate the theory of implantation. The 
present study was concerned only with the attempt 
at implantation of an extraneous organism, the 
Bacillus pyocyaneus, in the digestive tract of the 
guineapig. The aim had been to study the prin- 
ciples governing the implantation if such could be 
accomplished. Bacillus pyocyaneus had several 
advantageous characteristics for a study of this 
kind. It was potentially pathogenic; it produced 
poisonous substances in culture which in its patho- 
genic relationship it assumes in various character ; 
it could be fed in large numbers to the guinea- 
pig without causing ill efifects ; above all it was easy 
of recognition. With the exception of one experi- 
ment in which the guineapigs received the organism 
by stomach tube, the technic of the experiments was 
as follows : The guineapigs were offered various 
diets, and were fed the Bacillus pyocyaneus for 
three days. At variable lengths of time after this 
the animals were killed and culture made from the 
heart blood, the stomach, the duodenum, the ileum, 
the cecum, and the colon. 

The conclusions deduced from these experiments 
were that when guineapigs were fed on a diet of 
oats, hay, bread, and greenstuff, Bacillus pyocyaneus 
when fed disappeared from the gastrointestinal tract 
within three days. When oatmeal was given as a 
sole article of diet the Bacillus pyocyaneus had 
been found at seven and nine days after the last 
administration. The addition of a small amount of 
greenstuff, or of a certain amount of butter to the 
oatmeal diet, had apparently prolonged the period 
of persistence of the bacterium. Pyocyaneus on 
these slightly amplified diets had been found to 
persist about two weeks with considerable regu- 
larity. This increased persistence was probably 
apparent Only. The animals on a strict oatmeal diet 
did not live long enough to enable a complete experi- 



January 8, 1921.] 



LETTERS TO THE EDITORS. 



87 



ment to be carried beyond eight or ten days. The 
organism could not be recovered in any case after 
sixteen days. Judged by the amount of green color 
produced in the culture the number of surviving 
organisms became progressively less the longer the 
interval following the cessation of its ingestion by 
mouth. It was probable on the basis of these 
experiments that there was an efifect of dietary 
deficiency which consisted in the depression of a 
normal mechanism controlling the implantation of 
extraneous bacteria in the gastrointestinal tract. 

The Urgent Need of Dietetic Reform and the 
Duty of the Medical Profession Toward All the 
Young of the Nation. — Dr. E. W. Saunders, of 
St. Louis, drew a picture of the alarming physical 
degeneracy in the rural and urban population, one 
third of the youth of the nation being unfit for 
military service ; immigrants from the Ghettos of 
Europe rapidly degenerating in America, in spite 
of better wages and more abundant food ; negroes 
of the South physically unfit because of a diet of 
commercial corn meal, and Italians failing on maca- 
roni made from white flour. He asserted that the 
first measure to combat the high cost of living was 
to stop the denaturing of all foods by Federal law. 
Existing pure food laws were aimed against sophis- 
tication only. When these laws were passed, no one 
knew that deprivation of essential food elements 
contained in staple foods was , more deadly than 
sophistication or substitution ; nor did any one 
suspect that a diet of maintenance for the adult 
might fail to sustain growth in the young. Imper- 
fect and diseased teeth, fragile bones, weak muscles, 
exhausted nervous systems, recurrent infections, 
visceroptosis, stunted growth, inordinate appetite 
for sweets and meat, craving for stimulants 
and for excitement, inability for sustained effort, 
perhaps imperfect development of the endocrine 
glands, almost certainly a predisposition to can- 
cer, all this train of evils could be laid to the 
insane dietary of the American people of the 
present day. The remedy was twofold, diffusion of 
knowledge, and legislation. 

Medical Supervision of the Boarded Out Child. 

— Dr. Maynard Ladd, of Boston, described the 
work of the Boston Dispensary, which was started 
in cooperation with the Boston Children's Aid 
Society and the Church Home Society, two of the 
large child placing agencies, to demonstrate two 
principles: 1. The value of expert continuous 
supervision of children in the care of child placing 
societies. 2. The value of utilizing for the purpose 
the equipment and medical staff of an organized 
dispensary, including specialties in all the chief 
branches of medicine, in surgery, and in clinical and 
X ray laboratories for modern medical diagnosis and 
treatment. After describing the organization of the 
preventive clinic. Dr. Ladd presented a statistical 
study of 876 individual children. About five hun- 
dred a year were cared for. Of these, fifteen per 
cent, were sufficiently ill from one cause or another 
to be admitted to the children's hospital wards, 
which might be taken as a fair estimate of the hos- 
pital requirements of such a group of children. A 
little less than one third of the hospital admissions 



were for necessary tonsillectomies or adcncctomies. 
The low death rate of 1.1 per cent, undoubtedly 
was influenced by the prompt detection of serious 
cases of illness and the facilities provided for early 
and, if necessary, prolonged hospital care. The 
mortalit}^ statistics were interesting in the proof 
they offered of the practicability of reducing the 
death rate of a supervised group of children to a 
point below that which was accepted as normal for 
the community. There was a total of seventeen 
deaths in three years among 1,531 cases, amounting 
to one death a year for each one hundred children 
under their care. Equally interesting were the 
figures showing the effect of the special feeding 
clinic in the nutritional development of the first and 
second years. All the babies were fed on modifi- 
cations of cow's milk prepared in the foster homes 
and supervised by visiting nurses under medical 
direction. Seven tenths of these gained in weight 
considerably above the normal rate of the average 
healthy infant, and three tenths only failed to reach 
the normal rate by a small margin. 

The conclusion justified from this experience was 
that with proper organization and intelligent direc- 
tion the boarded out baby, even though deprived 
of its mother's milk, was a good medical risk, and 
need not be deprived of its fair chance in life. 
(To be concluded.) 

'^ Exam- 
filtering if necessary. The solution is ^hat did not 
an autoclave. It should not be use^f o.steoplastic 
fectly clear. We now employ icute osteomyelitis 
solution. The optimurn doJilg on at the end of 
twenty c. c. of this solutior has not been a single 



96 



NEUHOF AND HIRSHFELD: 



SODIUM CITRATE INJECTIONS. 



[New York 
Medical Journal. 



Admiuistratiou. — The solution is usually intro- 
duced into a vein at the bend of the elbow through 
a Fordyce needle with a twenty c. c. syringe. At 
least ten minutes should be consumed for the injec- 
tion of the drug. Otherwise it seems to us that 
serious manifestations may possibl)- follow, for they 
were observed in the experiments when citrate solu- 
tions were rapidly introduced. Our custom is to 
inject about two to three c. c, wait a few moments 
to see if any discomfort is complained of, inject 
another two to three c. c, and continue in this 
manner until all the solution is introduced. In the 
few instances in which we were in doubt as to the 
advisability of continuing the introduction of the 
citrate, we preferred stopping at a smaller dose 
than the one planned. If any of the manifestations 
to be described appear, we always await their dis- 
appearance before the injection. 

Since this paper was completed a death following 
a citrate injection has occurred in another's hands. 
The solution was not introduced according to our 
technic. Under the impression that we may pos- 
sibly not have laid sufficient emphasis upon the slow 
and intermittent introduction of the solution as 
ascribed above, the case is reported in detail. The 
notes have been obtained through the courtesy of 
Dr. A. A. Berg and Dr. E. Libman. 

Case. — A woman, sixty-nine years old, was 
operated upon for comrtion duct stone. Three days 
after operation there was oozing from the wound, 
after packings had been removed. As a prophy- 
lactic measure against further bleeding a sodium 
citrate injection was given. Sixteen c. c. of a 
thirty per cent, solution (4.8 grams) were intro- 
duced without pause within a five minute period. 
Directly thereafter respirations ceased, and the 
heart stopped beating several minutes later. At the 
postmortem examination by Dr. E. Libman there 
was no free blood found in the peritoneal cavity, 
and no evidence of thrombosis or embolism. There 
were adhesions from an old pericarditis, marked 
sclerosis of the thoracic aorta, and a small carci- 
noma of the stomach. 

It is in a sense fortunate that the first death 
following a sodium citrate injection should have 
occurred in a case in which there was a fatal prog- 
nosis from the gastric carcinoma, and it is signifi- 
cant that a dose of the drug less than the maximal 
dose accepted by others should have been followed 
by death. But the object lesson is clear. We are 
now no longer in the position of theorizing as to 
the absolute necessity for the slow and intermittent 
intravenous administration of sodium citrate, t^e 
conclusion derived from our animal experiments. 
The concrete case establishes the fact once and for 
all that sodium citrate is a very dangerous drug 
when injected intravenously w-ithout observing the 
nrecautions we have taken and advised. 
\. 'Tnife stations after injection of large doses of 

cai-^i... citrate. — The following have been noted: 

myocardu'^mbling of the lips, tingling sensations 

and efficienc '^s, dizziness, nausea, a sense of 

met shortly \. /'^.ss across the chest or abdomen. 

vascular system. ^ no manifestations referable 
D. — Systolic 140, g have been no untoward 

pulse rate 64. Abnormal 



aftereffects. No chills or elevation of temperature 
were observed with a single exception. A patient 
with a common duct stone and icterus had several 
chills with fever during his short stay in the hos- 
pital and suffered a chill with a rise in temperature 
one hour after the citrate was given. No alteration 
in blood pressure had been noted either during or 
after the introduction of the citrate. Sodium citrate 
is said to have a toxic effect on the kidneys, but 
we have been unable to verify this clinically even 
when very large doses were given. Up to the 
present the drug has been administered in only one 
patient suffering from a severe nephritis, and in 
this instance no toxic manifestations were noted. 
In short, we wish to emphasize the fact that no 
evidences of toxicity were observed in any of the 
hundred injections of large doses of sodium citrate 
that we have given up to and including a dose of 
fourteen grams. 

Turning now to the effects of large doses of 
sodium citrate administered intravenously in the 
human being, we may say at once that they corre- 
spond closely to those observed in our animal 
experiments. A similar drop in coagulation time 
occurs, the same change of the color of the venous 
blood to a light arterial tint is usually seen, and in 
all the cases of bleeding w^e have been able to 
observe, the hemorrhage was controlled. 

Change in coagulation time. — A typical curve of 
coagulation time after the optimum dose of six 
grams may be described as follows, the patient 
having a coagulation time of ten minutes : Five 
minutes after the injection the coagulation time 
drops to seven minutes, ten minutes later it reaches 
five minutes, in one half hour the coagulation time 
is between two and three minutes. The peak is 
reached some forty minutes after the injection, and 
is sustained in the neighborhood of a two minute 
coagulation time for an additional hour. The return 
to the normal then begins, but this is much more 
gradual than the rapid drop after the injection. In 
six hours the coagulation time reaches five minutes. 
Twelve hours after the injection it is still about 
seven minutes. The return to the normal occurs 
after a variable time ; in some instances the normal 
is reached in twenty-four hours, in others not until 
forty-eight hours or longer after the administration 
of the drug. No subsequent changes in coagulation 
time have been seen in observations taken two, 
three, four, five and six days after injections. The 
curve described is typical and figures closely 
approximating those given have been obtained in 
every instance in which such frequent observations 
could be taken. Of noteworthy interest is the fact 
that the coagulation time Avas shortened b}' citrate 
injections to a similarly striking degree in patients 
in which it was pathologically prolonged, especially 
in jaundice. We have noted drops in coagulation 
time from sixteen minutes before to two minutes 
following the injection. 

In the past few months almost all patients ad- 
mitted to our surgical service received citrate injec- 
tions and the pronounced change in coagulation time 
was seen in nearly every instance, regardless of the 
disease from which the patient was suffering. The 
coagulation reaction following citrate administered 



January 15, 1921.] NEUHOF .hXD HIRSHFELD: SODIUM CITRATE IXJECTIONS. 



97 



in optimum doses did not occur in a very few 
patients. The condition for which these patients 
came to the hospital offered no explanation for the 
absence of the reaction although it is possibly sug- 
gestive that three of them were suffering from 
cirrhosis of the liver with jaundice. The absence 
of any change in coagulation time following citrate 
injection in these cases will only be accounted for 
when the cause of the reaction is clearly understo6d. 
The cause of the changes occurring after citrate 
injection is unknown at the present time. 

There are some cases in which a more prolonged 
effect is desired than that obtained from a single 
dose of citrate. We have attempted to sustain the 
shortened coagulation time by repeating the dose 
after twenty-four to thirty-six hours. As a result 
the drop in coagulation time has been maintained 
in some instances for several days, to return to the 
normal in about a week ; in other cases the second 
dose has had little or no additional effect. We 
believe that the subcutaneous or possibly rectal 
administration of sodium citrate will possibly prove 
a better method when a slower and more sustained 
result is desired and we are now engaged in study- 
ing this question. 

Change in the color of the blood. — The change in 
the color of the venous blood to an arterial tint is 
usually present within five minutes of the intro- 
duction of the citrate solution. The return to the 
normal hue of venous blood is noted as the coagula- 
tion time again approaches that existing before the 
injection. In the small group of cases in which the 
coagulation reaction did not occur no change in the 
color of the blood was noted and we therefore 
regard this alteration in color as a characteristic 
element in the reaction. The appearance is that 
of venous blood that has been oxidized. We believe 
that spectroscopic and other studies may demon- 
strate that oxidization occurs as the result of the 
citrate injections. 

Consistency of the clot. — Concerning the clot that 
forms in the test tube or at the mouth of an injured 
vessel, there is every reason to believe that it is at 
least as solid after citrate injections as normally. In 
fact, we have gained the impression that a tougher 
and more solid coagulum results from the intro- 
duction of the citrate. The best demonstration of 
the adequacy of the clot is the permanent cessation 
of bleeding in the great majority of instances. 
There was no evidence of intravascular clotting in 
any of our experiments, and in none of the patients 
to whom citrate was given was there any suggestion 
of thrombosis or embolism. 

Control of bleeding. — Our evidence of the strik- 
ing and sometimes remarkable effects of large doses 
of sodium citrate on bleeding in human beings rests 
on purely clinical observations. It can truly be said 
that bleeding would have ceased spontaneously in 
some or perhaps many of the cases we have studied. 
Up to the present time, however, bleeding has been 
checked in every instance in which the citrate 
injection has been given for that purpose. The best 
proof that the cessation of hemorrhage is due to the 
citrate injection is that bleeding regularly begins to 
be controlled within fifteen minutes after the 
administration of the drug. 



Unless the underlying cause of a hemorrhage is 
cared for, recurrence of bleeding may of course 
take place, for the sodium citrate injection is only 
employed for the immediate control of hemorrhage. 
For example, a patient suffering from an incom- 
plete abortion had been bleeding continuously for 
several days ; bleeding stopped for twelve hours 
after the injection, and then recurred and continued 
until the uterus was emptied. There were three 
cases in which hemorrhage controlled by sodium 
citrate recurred after varying periods of time, to be 
definitely controlled by a second dose of the drug. 
These were one case of hemorrhage from a colos- 
tomy wound for carcinoma of the rectum ; one of 
hemorrhage from the abdominal wall after an ex- 
ploratory laparotomy for an inoperable carcinoma 
in a jaundiced patient, and one case of polycythemia 
with bleeding from the gums after the extraction 
of several teeth. 

In all the remaining cases a single dose of sodium 
citrate permanently controlled the hemorrhage. 
These cases may be arranged in four groups: 

Internal hemorrhage. — Blee(Jing was controlled 
in cases of hematemesis, rupture of the liver, trau- 
matic hemothorax, hemoptysis, and possibly in a 
case of cerebral hemorrhage. 

External hemorrhage. — These cases were varied. 
They included lacerated wounds, hemorrhage from 
the rectum, bleeding from raw areas left bare by 
operation, and postoperative hemorrhages from the 
rectum, gallbladder and prostatic beds. 

Bleeding encountered at operation. — There were 
a number of impressive examples at cranial, abdom- 
inal, and other operations. A remarkable instance 
was a case that proved to be cirrhosis of the liver 
with icterus. The intravenous injection of citrate 
was begun as the abdominal incision was made. In 
exploring the undersurface of the liver an alarming 
venous hemorrhage was started. Packings absolutely 
failed to control this, and the bleeding point or area 
could not be exposed. Without any other measure 
being employed, the bleeding quite suddenly became 
less and ceased soon after. The control of the 
hemorrhage occurred fifteen to twenty minutes after 
the introduction of the citrate. The excess blood 
was sponged away and the operation continued 
without further bleeding. 

. Bleeding anticipated during or after operation.- — 
In some cases it was difficult or impossible to deduce 
any effect from the citrate injection because of the 
necessary sponging at operation. In other instances 
in which citrate was given the operative field was 
manifestly less bloody than could have been ex- 
pected. A striking example was a case of carcinoma 
in which operation was performed recently by Dr. 
Lilienthal. A T incision was made, splitting the 
larynx and widely opening the pharynx transversely 
to expose the neoplasm. Except for a few arteries 
that were caught and ligated, the field was entirely 
free from oozing. Other cases were instances of 
jaundice with prolonged coagulation time. Exam- 
ples of anticipated postoperative oozing that did not 
occur after citrate injection are cases of osteoplastic 
craniotomy and operations for acute osteomyelitis 
in which oozing was still going on at the end of 
operation. In fact, there has not been a single 



98 



Hi'S!K: PHENOIODINE. 



[New York 
Medical Journal. 



instance of a postoperative hematoma in the wound 
since citrate injections have been used as a routine 
for all cases at the time of operation. 

CONCLUSIONS. 

1. The slow intravenous administration of large 
doses of sodium citrate given intermittently over a 
period of ten to fifteen minutes is nontoxic both 
experimentally and in the human being. In the 
latter, massive doses up to fourteen grams have 
been given without any toxic manifestations. 

2. The rapid intravenous administration of sodium 
citrate is dangerous and may be fatal both experi- 
mentally and in the human being. 

3. The optimum dose for adults is six to eight 
grams in a thirty per cent, solution and one to three 
grams in greater dilution for children. Doses for 
infants have not been determined. 

4. All types of bleeding, internal as well as surgi- 
cal, that have been encountered, have been controlled 
by large doses of sodium citrate administered intra- 
venously. 

5. Large doses of sodium citrate have been suc- 
cessively used to obviate hemorrhage in cases in 
which bleeding was anticipated at operation. 

6. This method of¥ers a large sphere of usefulness 
in the treatment of bleeding, is a simple application, 
and has proved both nontoxic and safe in our hands. 

We wish to extend our thanks to Dr. Howard 
Lilienthal for his courtesy and hearty cooperation 
in this work. 

REFERENCES. 

1. Weil, R. : Jotintal A. M. A., 1915, 64, p. 425. 

2. Ottenberg, R. : Proceedings of the Society of Ex- 
peritnental Medicine and Biology, 1916, 13, p. 104. 

3. KiNSELLA, R., and Brown, G. : Journal A. M. A., 
1920, 74, p. 1070. 

1000 Park Avenue. 

225 West Seventy-first Street. 



PHENOIODINE IN PNEUMONIA, SEPTIC 
INFECTIONS, AND ERYSIPELAS. 
By J. A. HusiK, A. B., M. D., 

Brooklyn, N. Y. 

This report is based on the work done by me 
in my private practice and subjoined will be found 
a presentation of cases by Dr. Herman Grad, at- 
tending gynecologist at the Woman's Hospital, 
New York, who at my request made use of the 
treatment in patients sufifering from puerperal 
sepsis, postoperative pneumonia, and erysipelas. 

I wish to state at the outset that I have no new 
theories to propound, that I lay no claim to the 
discovery cf any specifics, and that I do not pretend 
to understand fully how the coml)ination acts. All 
I wish to present here is the clinical results follow- 
ing the u.si of a combination of phenol and iodine 
Avhen administered intramuscularly as observed by 
my.iclf and others. It will not be out of the way, 
however, to mention the fact that some scientific 
investigation with phenoiodine solution was car- 
ried out di ring the war at one of the naval stations 
by Dr Wi'liam T. Moynan and here the fact was 
brought to light that the injection of phenoiodine, 
iatranniscularly, into the healthy human being 
produced a marked leucocytosis. The leucocytosis 



thus produced, however, was of temporary duration 
lasting no longer than three hours. Subsequent 
injections also served to bring about the same result 
but the leucocytosis was then neither as marked 
nor as lasting as after the first administration of the 
drug. Based upon these findings. Dr. Moynan used 
phenoiodine injections in the treatment of soldiers 
and sailors during an outbreak of septic sore throat 
and the results were described as highly satisfactory. 
The infection was rapidly overcome and the patients 
recovered within several days after the treatment 
was begun. I hope a separate report at some future 
date will be presented by Dr. Moynan. 

The method of preparing the phenoiodine will 
be given in detail at the end of this paper so as to 
enable anyone to make the drug for himself. The 
cost of the materials is so trifling as to be negligible. 
The labor involved is quite considerable but will 
be found no obstacle where the drug is really needed. 
It is my hope that physicians and surgeons in charge 
of large hospitals will give this form of therapeusis 
a fair and thorough trial. For it is my conviction 
that the therapeutic measure here advocated is of 
the greatest value when used at the proper time 
and in the proper case, that by its use a grave in- 
fection will often be turned into a mild one, that 
here and there the sacrifice of a limb will be avoided 
and that occasionally life itself will be saved. 

PNEUMONIA. 

Case I. — Male, aged sixteen, schoolboy. Family 
and previous history unimportant. .On March 2, 
1920, late in the afternoon, the patient experienced 
a severe chill which lasted ten minutes, and he com- 
plained of headache. Home remedies were first 
resorted to and an ordinary expectorant mixture 
was prescribed the next day by his physician. The 
patient continued to grow worse till the evening 
of the 4th. At this point I was summoned to see 
the patient. I found him in a condition of 
delirium. He was mumbling incoherently to him- 
self. The temperature was 104.4° F., pulse 128, 
strong and bounding; respirations were short and 
rapid, averaging 36. He was frequently coughing 
up a thick, tenacious, mucopurulent and bloody 
discharge. Physical examination showed consolida- 
tion of the upper right lobe and the greater portion 
of the lower left lobe. 

Treatment was instituted and carried out as fol- 
lows. Sinapism to chest and lower limbs and an 
ice pack to the head ; digitol in ten minim doses 
every three hours and a half ounce of whiskey in 
four ounces of milk were administered every three 
hours. Five c.c. of phenoiodine solution was now 
administered intramuscularly and repeated in six 
hours. At the end of twelve hours following the 
first injection temperature fell to 100°F. ; pulse 106; 
respiration 24. A third injection was now admin- 
istered. The patient's general condition under- 
went a most marked change within the twelve hours. 
He was no longer delirious, his breathing was 
deeper and free from pain, the cough lessened and 
the bloody discharge disa]:)peared. From a condi- 
tion pointing apparently to a fatal issue all signs 
seemed to point to a speedy recovery. On 
March 5th, at 8 p. m. the temperature rose to 100.5° 



January 15, 1921.] 



HiSlK: PHENOIODINE. 



99 



and the patient's general condition was not (|uite 
as good as during the day. A fourth injection of 
phenoiodine was now made. On the morning of 
the 6th the patient's temperature fell to normal 
apparently without the intervention of the usually 
expected crisis. In short, thirty-six hours after the 
first injection of phenoiodine and approximately 
ninety-six hours after the initial chill the pneumonic 
infection was overcome. All stimulation and in- 
jections were now discontinued, an expectorant was 
ordered and the patient made an uneventful 
recovery. 

Case II. — M. S., male, aged twenty-four; mar- 
ried ; merchant by occupation. Family and previous 
personal history have no bearing on the case. On 
May 6, 1920, patient fell ill with the grippe. His 
condition soon improved, but on the evening of May 
9th he experienced a slight sensation of chilliness, 
complained of headache and began to cough. The 
patient remained in bed using all he knew in the way 
of home remedies until I was summoned on May 
Uth, late in the afternoon. At this time the 
patient complained chiefly of his cough, pain in 
the left side and a feeling of extreme weakness. 
The cough was harsh and unproductive and no 
bloody expectoration was in evidence. Tempera- 
ture was 104°F., pulse 120 and respiration only 24. 
However, physical examination revealed an area 
of consolidation in the left lower lobe posteriorly, 
which in the presence of the patient's history and 
symptoms could not be taken for any other condi- 
tion than that of a lobar pneumonia. Bronchial 
breathing over the area involved was marked and 
a distinct dull note over the area could easily be 
delimited. 

The treatment consisted in moderate stimulation 
with whiskey and digitol. One injection of pheno- 
iodine was administered at 5 p. m. and repeated at 
12 p. m. On May 12th, at 9 a. m., the patient's 
temperature was 100° F. ; pulse 100; respiration 22. 
A third injection of phenoiodine was now admin- 
istered and repeated at 8 p. m. The following morn- 
ing the temperature dropped to 98° F. and pulse to 
90. In this case, as in the first one, there was no 
marked condition of crisis. The temperature came 
down gradually. The treatment thereafter was 
directed to alleviating the cough which continued 
troublesome for about a week in the absence of any 
fever or other symptoms of systemic infection. It 
took about ten days for the pneumonic signs to dis- 
appear completely from the lung. It would seem 
from this that the administration of phenoiodine 
intramuscularly in certain cases of pneumonia is 
capable of destroying the active infection quite early 
in the course of the disease process, although it takes 
the usual time for the products of the infection to 
become absorbed and eliminated from the system. 

Case III. — Girl, aged four. Had always been 
• well except for several attacks of bronchitis. For 
a day or two immediately preceding this attack the 
child had a slight cough which parents did not 
regard as important. On January 12, 1917, patient 
became suddenly very ill, complained of headache 
and vomited once. The patient was first seen at 
9 p. m. of the same day. At this time the child 
looked critically ill. The temperature was 105.5°, 



pulse rate was 160, and respirations 48. De- 
lirium was not present but the patient was restless 
and paid little attention to what was going on about 
her. Plivftical examination revealed a small patch 
over the right lower lobe where both anteriorly and 
posteriorly soft, moist rales could be heard. On 
auscultation bronchovesicular breathing could be 
made out over the area involved and the percussion 
note was slightly duller than over the rest of the 
right lung. The left lung was free from disease. 
The usual local and stimulant medication was 
ordered and half the adult dose of phenoiodine was 
administered into the gluteal muscles. This was 
repeated after twelve hours. At the end of the 
first twenty-four hour period following first injec- 
tion temperature fell to 99° F., pulse to 108, and 
respirations to 28. No further injections were 
made. Ordinary stimulation was continued for 
several days longer and expectorant treatment was 
added. The child made a full recovery in a week. 
There was no further rise in temperature. This 
was the only case in which such marked and rapid 
change had been observed as it is also the only one 
in which treatment was begun so early in the course 
of the disease. 

Case IV. — This is a case of inhalation pneumonia. 
An Italian laborer aged forty-four, painter by 
occupation, fell down a scaffolding and sustained 
a fracture of the nose. He received the usual treat- 
ment by a surgeon at a hospital. Several days later 
cough and pain developed in the right side of the 
chest anteriorly. The pain was referred to the 
sternum. His temperature soon rose to 103.6°, 
pulse to 114, respirations 30. The cough was un- 
productive at first and no blood was present. 
Physical examination showed a small area of the 
right lung presenting the usual signs of inflamma- 
tion in this organ. Rales were present, with 
modified vesicular breathing and a dull percussion 
note. The -attending surgeon agreed that we were 
dealing with an inhalation pneumonia. Treatment 
was now begun and consisted in the ordinary form 
of stimulation and phenoiodine injections were 
administered once every eight hours. In all, five 
injections were made. At the end of forty-eight 
hours the patient's temperature, pulse, and respira- 
tions came down to normal and he made a perfect 
recovery without any further trouble from the 
infection in his lung. 

Case V. — This case is reported under pneumonia 
for the reason that a pulmonary process developed 
in both lungs during the course of a far graver 
systemic condition. The patient was a middleaged 
woman, single, high school teacher, weighed 240 
pounds. Her family history was negative. The only 
fact in her personal history that had any bearing 
on the case was that she had been a frequent suf- 
ferer from tonsillar infections and that she had had 
a polyarthritis several times before the onset of the 
present illness. On June 6, 1918, the patient suf- 
fered from an attack of follicular tonsillitis from 
which she rapidly recovered. She remained well 
until the 26th, when suddenly her joints began to 
swell. Every large joint in the body became in- 
volved in the course of several days. On July 1st 
there appeared a murmur over the mitral area, and 



100 



HUSIK: PHENOIODINE. 



[New York 
Medical Journal. 



on July 3rd there developed a pulmonic infection 
in both lungs. A blood culture made in this case 
showed the streptococcus. The discharge from the 
lungs showed both the streptococcus and the pneu- 
mococcus. ■ The urine showed albumin, numerous 
pus cells, and granular and hyaline casts. The 
temperature varied between 103° and 106° F. ; pulse 
range was between 120 and 140, and respirations 
averaged 36. 

Throtigh the courtesy of Dr. Ellen Lysaght, the 
attending physician, I was called in to see the pa- 
tient on the third day after the appearance of the 
pneumonic lesions. It will be admitted that in the 
presence of the findings stated above the condition 
of the patient was most serious, the prognosis 
grave and a fatal issue was the termination to be 
expected. At this point, however, injections of 
phenoiodine were commenced at intervals of four 
hours. All antirheumatic treatment previously em- 
ployed was discontinued ; stimulation was given 
as before. After two days of treatment the patient 
showed a great deal of improvement. The swell- 
ings in the joints were markedly decreased, the 
lung condition improved, the temperature range 
fell to between 101° and 102° F. Her pulse and 
respirations showed a marked change for the better. 
The injections of phenoiodine were now reduced 
to three daily. With the reduction in the frequency 
of phenoiodine administration all the symptoms and 
signs showed a tendency to become increased so that 
more frequent injections had again to be resorted to. 
In all, ninety-six injections were administered dur- 
ing the course of the illness, which lasted six weeks. 
By August 15th the patient's condition became nor- 
mal. The infection was completely overcome. On 
September 15th a pleurisy with effusion developed. 
Thoracocentesis was now done and a quart of turbid 
fluid removed from the chest but there was no pus. 
She again made a rapid and complete recovery. 
On January 1, 1919, the patient resumed her work 
of teaching and has remained well since. The latest 
report by Dr. Lysaght states that there is at present 
only a slight cardiac murmur over the mitral area. 

Other cases of pneumonia could be reported 
from my own practice as well as from the work 
of others who have employed the treatment, but 
that would only be tedious repetition. One fact 
should here be emphasized. In order to be 
efficacious the treatment must be instituted as early 
as possible in the course of the disease. When 
started seventy-two hours after the onset of the 
pneumonia it has little influence on the course of 
the disease. I may also add that while no bacteri- 
ological studies have been made except in the 
instance mentioned above it is my opinion that 
those pneimionias will be chiefly influenced by the 
treatment in which the pus forming group of 
bacteria are as much implicated in the production 
of the toxemia as those that belong to the pneumo- 
coccic group. 

SEPTIC INFECTION. 

Case. VI. — A laborer sustained an injury of the 
hand. Three days later his arm began to swell. 
In spite of the usual treatment applied to the local 
wound the arm continued to grow worse. Six 



days after the infliction of the wound the infected 
arm grew to double the normal size, the patient 
became septic and showed the usual septic tempera- 
ture varying between 103° and 106°. The pulse 
varied between 110 and 140. He had frequent and 
profuse perspiration and was greatly prostrated. 
A surgeon was consulted and he advised immediate 
removal to the hospital for the purpose of amputa- 
tion at the shoulder joint. The patient refused. At 
this point treatment by phenoiodine injections was 
commenced. One five c. c. ampoule was adminis- 
tered every three hours for the first six doses. The 
patient's condition had by now improved so 
markedly that it was deemed safe to reduce the 
frequency of the injection to once every six hours. 
At the end of forty-eight hours the temperature 
fell to 99°F., pulse to 85. The swelling was con- 
siderably reduced. Prostration was no longer 
present. Fifteen injections were administered in 
all and the patient made a very good recovery 
within a week after treatment was begun. Other 
treatment consisted in stimulation with alcohol and 
keeping up of the strength by liquid diet. A second 
case practically identical in its details was treated 
the same way and also with the same result. 

erysipelas. 

Case VII. — Male; aged thirty-one; school 
teacher; single. Family and personal histories were 
unimportant. On a Monday afternoon when 
returning from school he began to feel an itching 
and burning in his right foot. When the shoe was 
removed the foot was found to be red, the 
discoloration extending over the entire dorsum with 
a sharp line of demarcation between the healthy 
and diseased areas. The same evening the patient 
was seen by me together with Dr. William T. 
Moynan, who was then connected with the Post- 
Graduate Hospital, New York. We both agreed 
that the case was one of erysipelas. The tempera- 
ture at 9 p. m. was 104°F. ; pulse 114. The patient, 
however, did not look very ill. The treatment 
consisted in the immediate administration of 
phenoiodine followed by the local application of an 
ichthyol dressing. No medication by mouth was 
ordered. The following morning, 10 a. m., patient 
felt much better. The itching and burning sub- 
sided and the patient's temperature fell to 97.8°F. ; 
pulse 70. A second and last administration of the 
phenoiodine was now made and the ichthyol dress- 
ing was continued for several days longer. No 
other treatment was employed. The recovery was 
complete as evidenced by the fact that on the fol- 
lowing Saturday the patient was able to attend 
a ball and to participate in the dancing. 

Case VIII. — Female; Italian; aged thirty; mar- 
ried ; had two children. February 2, 1919, the 
patient began to complain of a burning sensation 
in both cheeks. I was first summoned on the • 
morning of February 4th. I found the patient quite 
ill. Her temperature was 103.8°F. ; pulse 120. 
She complained of headache and a feeling of 
nausea. Did not vomit. Both cheeks by this time 
showed considerable tumefaction and sharply de- 
fined areas of redness covered both cheeks extend- 
ing from the angle of the mouth almost to the ear. 



January 15, 1921.1 



GR.ID: PHENOIODINE. 



101 



and from the lower borders of the rami of tlie jaw 
upward toward the zygoma. The erysipelatous 
areas were peculiarly symmetrical. The diagnosis 
of erysipelas was made and injections of pheno- 
iodine were immediately instituted. One injection 
was made on the fourth and repeated eight hours 
later. On the morning of the 5th the patient was 
found markedly improved in every way. Tume- 
faction of the face was gone, pain and burning 
disappeared and instead of the intense redness the 
color of the cheeks became light pink. Temperature 
and pulse were found to be normal. A simple tonic 
was now prescribed and the patient was discharged. 
She made a complete recovery. 

Case IX. — Male, aged sixty-four, watchman. 
Previous history unknown. This patient had a 
deep and long incision made along the back of the 
neck by his physician who mistook the condition 
for a cellulitis. No pus was found. There was 
an intense red area occupying the whole back of the 
neck. There was a sharp demarcation line between 
the diseased and healthy skin. The patient was 
found to be very ill indeed. His temperature was 
104°, pulse 120 and he was greatly prostrated. One 
injection of phenoiodine was made and repeated 
the next morning. At my second visit the patient 
was very much improved. His temperature fell 
to 99° and varied between that and 100° for several 
days longer. Owing to the patient's age, his low 
general vitality and the poor hygienic surroundings 
the incision made was about six weeks in the 
healing. Also because of these conditions an ab- 
scess developed at the sight of injection. The pus 
was readily evacuated by a small incision and healed 
long before the incision in the neck closed up. In 
the course of my experience extending over six 
years this is the only instance where abscess forma- 
tion had occurred. This was due in my opinion 
to the patient's low state of vitality as well as to 
the comparatively filthy surroundings in which pa- 
tient lived. 

UNTOWARD EFFECTS. 

In a period of over six years during which I 
have administered, conservatively speaking, be- 
tween three and four thousand injections I have 
seen no untoward effects save the case of abscess 
mentioned. I have observed no reactions local or 
general following the administration of the drug. 
Some of the patients can taste the drug soon after 
it has been administered. Others smell it in their 
perspiration and in the urine. It can be readily 
recovered from the urine and the feces. However, 
the following was reported to me by others who 
made use of the drug. In one case, in a woman 
eighty-four years of age, who had been suffering for 
three months from unresolved pneumonia, there 
developed a suppression of the urine after the 
exhibition of the drug. Another physician who had 
used the drug reported the onset of an acute 
nephritis. In this case we believe it was pure 
coincidence. For in dozens of other instances in 
which he had administered the drug he had observed 
no ill effects whatever. In one of the cases reported 
by me above the presence of albumin, pus and casts 
in the urine did not contraindicate the use of the 
drug. Ninety-six injections were administered in 



that case and if the drug had the natural tendency 
to bring on an acute nephritis it should have done 
so in that case. But instead of that the kidney 
condition cleared up together with the rest of the 
infectious process. Dr. Herman Grad reports ab- 
scess formation. However, the administration of 
the drug was in these cases made by the nurses in 
charge and good judgment is necessary in selecting 
the site for injection where the same has to be 
given every three or four hours. No abscess forma- 
tion should occur with proper technic. In Dr. 
Grad's patients, however, even the formation of 
abscess will be no bar to the administration of the 
drug for in them the question of saving the patient's 
life is the immediately pressing one. I know of no 
other instance of any ill effects. If there are any 
they were not reported to me. 

METHOD OF PREPARING THE DRUG. 

The iodine to be used must be resublimed at 
least several times. For each dose to be made four 
grains of phenol and two grains of iodine are 
measured off accurately and placed in an Ehrlen- 
meyer flask. Five c.c. of a sterile normal saline 
solution is now added for each dose to be made 
and the whole is placed in a water bath from one 
to two hours. This process results in the forma- 
tion of the monoiodide of phenol plus a very small 
quantity of the diiodide. The liquid is now allowed 
to stand till it has cooled perfectly and the diiodide 
has separated out and settled to the bottom. The 
monoiodide solution is now poured off into a 
sterile container and transferred to amber colored 
ampoules of five c. c. capacity. These ampoules 
must be kept in the dark in which manner the 
product remains stable for at least six months. 

Dr. Grad's report follows. 

2559 Bedford Avenue. 



PHENOIODINE IN PUERPERAL SEPSIS 
AND POSTOPERATIVE PNEUMONIA. 
By Herman .Grad, M. D., 
New York, 

Attending Gynecologist to Woman's Hospital. 

My attention was called to phenoiodine by Dr. 
Husik, several years ago, and I have used it as a 
therapeutic measure in several cases of puerperal 
sepsis and in postoperative pneumonia with much 
success. I feel that it should be used in every case 
of puerperal sepsis. As a therapeutic measure it is 
worthy of careful investigation by clinicians as well 
as laboratory workers. I feel that it is a thera- 
peutic measure of great value and has immense 
possibilities for favorably influencing septic condi- 
tions of the body. 

My experience with phenoiodine is entirely a 
clinical one. I have made no experiments with the 
solution and know nothing of its physiological 
action. All I can say is that it does favorably 
influence septic processes in puerperal septicemia, 
and that the clinical course of the disease is markedly 
affected by the administration of the drug. In sep- 
tic postoperative pneumonia it has a decidedly bene- 
ficial effect which is often striking. The admin- 
istration of a few doses of phenoiodine will cause 



102 



GRAD: PHENOIODINE. 



[New York 
Medical Journal. 



a prompt amelioration of symptoms and will turn 
a very distressing condition into a safe clinical 
course of the disease. I have seen cases with most 
alarming clinical symptoms, high temperatures, 
severe pain in the chest with a distressing, dry, 
harassing cough, benefited by a few doses of pheno- 
iodine to a phenomenal degree. The symptoms 
promptly subside, expectoration becomes profuse, 
temperature and pain subside and convalescence 
becomes established. It is the remedy par excel- 
lence. I am so convinced of the positive therapeu- 
tic action of phenoiodine in postoperative pneu- 
monia that I have no hesitation in calling it a life 
saving therapeutic measure. 

In a case of erysipelas its action was most marked. 
Without any local application the lymphangitis sub- 
sided promptly. The tumefaction in the skin and 
the pain promptly disappeared and in less than 
forty-eight hours the disease was under control. 
Of course one case proves little but Dr. Husik tells 
me that the action of phenoiodine in erysipelas is 
striking. 

I beg to report the following cases : 

Case I. — Mrs. R., aged thirty-one, para three, was 
confined ten days previous to my consultation with 
a low forceps operation. She sustained a moderate 
degree of perineal laceration. On the third day a 
sepsis appeared. There was a chill and the tem- 
perature rose to 105° F. For the next six days the 
temperature fluctuated between 100° and 105°. 
There was pain in the lower abdomen and profuse 
perspiration. Abdominal distention, coated tongue 
and constipation were all present. The patient was 
in a great state of apprehension having been told 
that an operation was necessary to evacuate pus 
from the pelvis. I was called in consultation on 
this account. Pelvic examination showed uterus 
and adnexa fixed by a solid exudate in the pelvis 
with no point of fluctuation. I advised against 
operative interference and recommended pheno- 
iodine injections. Within three days after the first 
injection the temperature showed a decided tend- 
ency to subside and within a week the temperature 
was normal and remained so. The patient received 
thirty-six injections in all. The pelvic exudate 
completely disappeared with no pus formation. 
During the septic process a polyarthritis developed, 
both knees, one wrist, and both sacroiliac joints 
being involved. These joint involvements promptly 
subsided the last one to disappear being the right 
sacroiliac joint. The patient made a complete 
recovery. My feeling in this case is that the pa- 
tient would have recovered without the use of 
phenoiodine but that her recovery would have been 
a matter of months instead of weeks. That pheno- 
iodine hastened her recovery and made her recovery 
more complete without further complications of a 
septic nature is beyond doubt. 

The following case of puerperal sepsis was a 
remarkable one and I feel that recovery was to 
a very large measure due to the use of phenoiodine. 
I say this because I wish to be conservative in my 
statements. The truth of the matter is that clini- 
cally the case was a fatal one of puerperal sepsis 
and that phenoiodine was a life saving agent in this 
instance. 



Case II. — The patient was a young woman, 
twenty-one years old, primipara, who was confined 
six days before my consultation. She had been con- 
fined in a tenement house. There had been a forceps 
operation and the placenta was removed manually 
as well as by curette. Two days later her tempera- 
ture rose to 102° F., and she was again curetted. 
The temperature now- went up to 106° and she had 
severe rigors and vomiting. Her abdomen was 
distended and she was not only profoundly septic 
but she also showed signs of an active peritonitis. 
When I saw the patient she presented the picture 
of a fatal case of puerperal sepsis. Her tempera- 
ture was 106° and she was delirious. Pelvic 
examination showed a tender, subinvoluted uterus 
with no exudate or masses. Her history, clinical 
signs, her pulse and general appearance made so 
unfavorable an impression on me that I gave a 
fatal prognosis to the attending physician and a 
guarded prognosis to the family. However, pheno- 
iodine injections were advised and it was to be used 
in five c.c. doses repeated every three hours. After 
eight doses a marked change occurred in the clini- 
cal course of the disease. The delirium disappeared, 
peritonitis subsided, temperature and pulse were 
lower, and in every way the patient was better. 
Twenty-four doses in all were administered and 
convalescence was established. Two large abscesses 
developed at the site of injection. The pus was 
evacuated and the patient made a complete recovery. 

I have used phenoiodine in seven other cases of 
puerperal sepsis, in every case with benefit to the 
patient. It would be useless to detail their histories 
as it would be a repetition of the two cases reported 
above. Suffice it to say that my experience with 
this therapeutic agent leads me to feel that it favor- 
ably influences puerperal sepsis and should be used 
in every case. 

POSTOPERATIVE PXEUMOXIA. 

I was greatly impressed with the therapeutic 
value of phenoiodine in the following case of post- 
operative pneumonia. 

Case HI. — Mrs. A., aged twenty-nine, was oper- 
ated on for a subacute appendicitis and retroversion 
of the uterus. She was a short necked, fleshy wo- 
man subject to bronchitis. At the time of the 
operation there was no sign of pulmonary disturb- 
ance. The operation was a comparatively short one, 
but on the day following the anesthesia cough and 
pain in the chest developed. Examination of the 
chest showed a consolidated right lower lobe of the 
lung. The temperature rose to 104° F., with a high 
pulse, great pain in the chest, the cough was dis- 
tressing. Hps blue, fingernails blue, with frequent 
and embarrassing respiration. The patient appeared 
very ill and it was distressing to note that none of 
the usual therapeutic measures brought relief to the 
patient. Twenty-four hours later the prognosis ap- 
peared doubtful. The pneumonic process appeared 
to have extended and the opposite lung showed 
areas of involvement. The administration of pheno- 
iodine was now started, five c. c. being administered 
intramuscularly every three hours. After the third 
dose the cough was less distressing, expectoration 
was established, and the patient slept for an hour. 



January 15, 1921.] 



GEYSER: PHTHISIS PULMONALIS. 



103 



This was the first sleep she had had since the 
operation without the use of morphine. Within 
twelve hours after the first dose of phenoiodine 
was administered a decided improvement had 
occurred in the condition of the patient, and after 
twenty- four hours a phenomenal improvement 
was apparent. The therapeutic efifect of pheno- 
iodine in this case was a revelation to me. Twenty- 
four hours later all her symptoms — pain, cough, 
temperature, rapid respiration, blue lips and nails — 
had abated, and convalescence was established. 

I have used phenoiodine solution, kindly supplied 
by Dr. Husik, in five other cases of postoperative 
pneumonia and in every case the therapeutic efifect 
was definite and effective. I have no hesitation 
in recommending this curative measure in every 
case of pneumonia coming on after operation. I 
feel sure that every surgeon will be interested be- 
cause I know how promptly it acts and how benefi- 
cial it is to the patient. 

In two cases of infarct pneumonia following 
operation, empyema developed in spite of the use 
of phenoiodine, and resection of the ribs had to 
be done. In both of these cases — one a gangrenous 
appendix and the other a septic cholecystitis — the 
pneumonia was most favorably influenced by the 
phenoiodine. This was shown by the prompt 
amelioration of cough, pain, rapid respiration and 
physical signs. I feel sure that in the use of pheno- 
iodine as recommended by Dr. Husik we have a 
definite therapeutic measure that is as prompt as it 
is efficacious in its therapeutic action. 

40 East Forty-first Street. 



PHTHISIS PULMONALIS.* 

By Albert C. Geyser, M. D., 
New York. 

The subject of phthisis pulmonalis is such a large 
one and may be viewed from so many different 
angles that it will be possible for me merely to call 
attention to some of the more important and fre- 
quently misinterpreted phases of the disease. 
Neither will it be possible for me to introduce any- 
thing new. All that I shall say is well known to 
you, but I shall try to direct your attention to 
phases of the disease which may have escaped your 
attention heretofore. In fact, some of my state- 
ments may seem almost heretic. Whether my con- 
ception of this disease is right or wrong, I will 
leave to your judgment. I myself am guided en- 
tirely by the practical results obtained from thera- 
peutic measures in harmony with my viewpoints. 
cause. 

Two factors are necessary for the existence of 
this disease, namely, a suitable soil (lowered re- 
sistance), and the specific seed (the germ). A suit- 
able soil is furnished by anything which lowers the 
physical resistance of the individual. The specific 
germ is always with us. In ninety per cent, of 
all human beings the germ is transmitted during 
intrauterine life. The other ten per cent, are 

*Delivered before the meeting of the American Association for 
Medicophysical Research, October 7, 1920, Chicago, 111. 



promptly infected during their first tew weeks of 
independent existence. 

This disease is a concomitant of civilization. 
Only a few barbaric and semicivilized peoples are 
still free from it. Such individuals are virgin soil 
and become rapidly infected after contact with the 
civilized. The average life of the Eskimo is two 
and a half years after an attempt at becoming 
civilized. In civilized communities the disease is 
seldom or never propagated from the sick to the 
healthy. The apparently healthy are already tuber- 
culized. They have either been infected during 
life in utcro or immediately thereafter; they have 
recovered and are more or less immune ; they har- 
bor within their systems the germs. Everybody is 
a potential consumptive. Since the germs do not 
thrive and multiply, they have not the disease in 
fact, but are latent cases. A very few may become 
entirely free from the germs, but are nevertheless 
tuberculized. For confirmation I have only to point 
to the fact that neither doctors, nurses, nor attend- 
ants at sanatoria show any special percentage of 
infection. There are few cases on record where 
the husband or the wife have apparently infected 
each other. In families with consumptive children, 
only one or two showed the disease, yet in all these 
cases there was unhindered contact day in and day 
out. 

BOVINE tuberculosis. 

The acid fast bacillus found in cattle does not 
cause phthisis in the human. If the fresh milk, 
which may contain these bacilli, did cause the dis- 
ease in the human, then the farmer's children would 
be the first ones to suffer, because they drink the 
fresh, warm milk. The dairy workers also would 
show a high percentage of infection, owing to their 
close and constant exposure. The children and 
individuals of the city, far removed from the cattle, 
living on pasteurized and sterilized milk, fall easy 
victims to the disease. It is more likely that the 
human phthisis patient by his expectoration infects 
the cattle. After the germ has passed through an 
existence in cattle, by attenuation it may have be- 
come weakened in the same manner as a germ of 
smallpox. 

the physiological method of cure. 
Up to 1882 it was well known that persons who 
died from what was called phthisis or consumption 
showed after autopsy that their lungs were studded 
with small granules. These granules, or tubercles, 
were an ever present accompaniment of this dis- 
ease. It was thought that they were either the 
result of or at least played an important part in the 
disease process, hence the term tubercle disease or 
tuberculosis. During the year of 1882, Koch, of 
Berlin, discovered that every one of these tubercles 
contained one or more acid fast bacilli ; that these 
bacilli were surrounded first by a circular layer of 
giant cells, then by a layer of ovoid cells, and lastly 
by a third layer of round or leucocyte cells. En- 
meshed within these last cells were usually some 
lime salts. In a completely formed tubercle there 
was not discovered a single trace of blood vessels, 
showing that the centrally located bacilli were by 
this means most effectually shut off from all out- 



104 



GEYSER: PHTHISIS PULMONALIS. 



ORK 

Medical Journal, 



ward communication or escape. The entire tubercle, 
however, might be expelled from the lungs the 
same as any other foreign body, or it might remain 
in situ as a bullet after having become encapsulated. 
The fibrous capsule surrounding a bullet or the 
formation of pus cells around a splinter are both 
analogous processes to the formation of the tubercles 
around the bacilli in the lung tissue. 

These three processes are physiological and not 
pathological. Tubercle formation, therefore, is a 
conservative process ; it is Nature's method of 
making the otherwise injurious bacillus practically 
harmless. That such a process should not be inter- 
fered with is selfevident; on the contrary, it is our 
duty to assist Nature in her effort. All therapeutic 
measures not in harmony with natural laws, while 
they may appear highly scientific, are not' physio- 
logical, therefore of questionable value. 

For several centuries we have passed through 
tuberculosis crusades. In some countries they have 
taken on the appearance of actual persecutions of 
the unfortunates and the destruction of their be- 
longings. During later years these crusades have 
donned the financial, political and educational garb. 
After all the crusades, isolations, tuberculin injec- 
tions, creosote inunction and inhalation, the percent- 
age of the stricken is about the same. The death 
rate has not changed and the building of sanatoria 
goes on. All this appears as proof positive that 
all of these measures have been tried and they have 
been found wanting. 

PHYSIOLOGICAL TREATMENT OF PHTHISIS. 

Under no circumstances should a patient be sub- 
jected to treatment based upon the x ray findings. 
It is just as illogical to treat a clinically symptom 
free patient for consumption because the x ray 
shows lesions as it is to treat a patient simply 
because he has a four plus Wassermann. Neither 
the X ray plate of the lungs nor the four plus Was- 
sermann of the blood has any significance in the 
absence of clinical symptoms. I desire to call your 
attention to a few very important points. Do not 
treat the disease, but treat the patient. While this 
rule applies to all diseases and all patients, it is 
of especial value in consumption. Since every 
human being is more or less tuberculized, and since 
only one seventh of the entire race dies of con- 
sumption, it follows that there must be all grades 
of conditions between the two extremes. Not only 
that, but the consumptive is ever hopeful of re- 
covery and this psychic condition must be taken 
advantage of to the fullest degree. 

The treatment in general may be divided into 
local and constitutional. It is to be understood 
that every local treatment produces a constitutional 
efifect and every constitutional measure affects the 
local lesion. 

General constitutional therapy. — Consumption is 
a wasting disease ; it uses up tissue faster than the 
patient can produce it; rest is therefore of para- 
mount importance. To rest does not necessarily 
mean being in bed. Whenever possible, and as a 
rule it is always possible, the patient should spend 
only the regular hours during the night in bed. 
At all other times he should be fully dressed, though 



lie may spend his time in a hammock or reclining 
chair. Whenever possible he should take some 
regular outdoor exercise from a mere fifteen minute 
walk to playing games. Do not worry about the 
fever; it will take care of itself — but more of this 
later. 

Outdoor air. — The best climate for a patient with 
this disease is the one where he can spend twenty- 
four hours of each day out of doors. It matters 
little where this climate is found. As a general 
proposition for those who can afford it, it is South 
in the winter and North in the summer. The whole 
secret of the outdoor treatment is to be found in 
the fact that every person, sick or well, is sur- 
rounded by a certain circular zon^ in which his 
own emanations are continuously given off. A con- 
sumptive gives off a certain odor, the reinhalation 
of which is not conducive to his best interest. As 
long as such a person is confined to a room, so long 
is he obliged to undergo this reinhalation process ; 
but while he is outdoors the air currents are con- 
stantly removing these personal emanations and as 
a result he breathes fresh air instead of his own 
stale effluvia. 

Altitude. — Some patients do well at the higher, 
others at the lower altitudes ; some succumb at 
both. It is not always easy to decide just where 
certain patients should be sent, assuming that they 
are to be sent away from home at all. As a general 
proposition the physically strong and robust patient 
with a good chest expansion will do well in the 
higher altitudes, while the weak, shallow chested 
individual does better at the sea level. There is yet 
a third class of patients, those who can take a deep 
breath but through force of habit never do. Such 
a patient should be sent to a gradually increasing 
altitude, while those who are perfectly willing but 
cannot take a deep breath must live as near to the 
sea level as possible. Now these are arbitrary state- 
ments, but they are in perfect harmony with the 
laws of physiolog3^ The barometric pressure at 
the sea level is fifteen pounds to the square inch; 
the higher we ascend into the mountainous regions, 
the less is the air pressure. The more rarefied the 
air becomes, the greater must be the effort at 
breathing. For suitable cases such an effort be- 
comes a lung gymnastic which must be of benefit 
to the individual. When, therefore, the all too 
common error is made of sending the weak, frail, 
small chested individual to the mountains, he not 
only fails to improve, but spends what little power 
he may possess in a useless effort ; he literally wears 
himself out trying to breathe sufficient oxygen to 
maintain life. The average patient recovers best 
at or near the same atmospheric and climatic condi- 
tions where he or his parents were born. Such 
conditions are natural to him ; he does not have 
to acclimate himself. 

Diet. — Consumption is a disease in which either 
tissue metamorphosis is markedly increased or else 
there is some interference with tissue assimilation. 
It is a process of gradual wasting. Proteins are 
the foodstuffs that maintain body weight and repair 
tissue waste ; they are therefore indicated. Do not 
attempt to fatten a patient ; a patient may gain in 
weight, yet suffer from consumption. As a general 



January 15, 1921.] 



GEYSER: PHTHISIS PULMONALIS. 



105 



proposition allow each patient to select his own food, 
especially those foods which the patient knows from 
actual experience to have agreed best with him in 
the past. 

I would warn you against urging the use of raw- 
eggs. Raw albumen is not only difficult to digest, 
but is hkely to cause the patient to become "bilious." 
There is, on the contrary, not the least objection 
to the use of hard boiled eggs, providing they are 
known to be reasonably fresh. Pure, rich milk, or 
fresh cream and water, is a valuable asset. Do not 
use pasteurized or sterilized milk if you can help it ; 
such milk is lacking in vitamines. Since the physio- 
logical process of forming tubercles requires lime 
salts, there is no better or more natural way of 
obtaining these than by having the patient take one 
or two ounces of clam or oyster juice once or twice 
a week. 

Hygiene. — No matter how well a room may be 
ventilated, it does not compare with outdoor air. 
Every consumptive must be taught how to breathe 
properly ; the breathing is too shallow in all of them. 
Beside the usual bathing, a patient must take a 
hot bath at least every other day. The bath must 
produce free perspiration and be continued not less 
than fifteen to thirty minutes. The hot. bath, at a 
temperature of 107° F., is followed by a short cool- 
ing bath at a temperature of 80° F. This prepares 
the patient for a rub down or light massage just 
before retiring. 

Whether there exists constipation or not, the 
rectal douche should be used at least on alternate 
days. Do not fear the douching habit — there is 
no more harm in regularly douching the rectum 
than there is in regular mouth washings. 

Local treatment. — The patient's own blood must 
be caused to contain all the elements necessary for 
a cure. When the hemoglobin percentage is below 
eighty, the intravenous injection of cacodylate of 
iron is the only remedy indicated. Five c. c. are 
used once or twice a week until the blood improves. 
At the present time there is only one way in which 
the amount of blood can be increased through the 
lung tissue, and that is by the use of diathermia. 
It heats the entire pulmonary area through and 
through ; it dilates the pulmonary capillary system, 
thereby causing diapedesis of the leucocytes. The 
fixed cells respond as a result of this by the forma- 
tion of giant cells around the bacilli ; because of 
the capillary dilatation and the increased diapedesis, 
the wandering cells surround the giant cells, com- 
pleting Nature's method by the creation of the all 
necessary tubercle formation. The earthy material 
from the clam and oyster broth furnishes the neces- 
sary lime salt which is enmeshed in the third or 
outer layer of each tubercle to make assurance 
doubly sure that the escape and future damage by 
the bacillus is made impossible. 

Temperature. — Just a few words concerning the 
fever. The irregular temperature is a curative 
process ; it is the result of reaction to something 
within the system. It is also evident that no matter 
how high this temperature may be, it is inadequate 
in amount. It may be adequate for the time being, 
the temperature returning to normal or, from ex- 



haustion, to subnormal. There may be a new pour- 
ing out of that something which caused the first 
reaction, so that we have a continuous attempt on 
the part of the system to overcome or cure some- 
thing. Taking this view of the rise and fall of the 
patient's temperature, are we warranted in doing 
anything . that would interfere with this curative 
process ? 

The answer is self evident. The patient's tem- 
perature should be taken upon awakening in the 
morning before getting up, again during the middle 
of the day, and once more in the evening. These 
three temperatures are then added together and 
divided by three. If the quotient shows one or 
two degrees above normal, that patient is in a fair 
way to recovery ; if, however, the patient's daily 
average temperature is below normal, the prognosis 
is correspondingly bad. The temperature in con- 
sumption may be too low; it is never too high. 
This explains the efficacy of the diathermic phase 
of the high frequency current. One must, how- 
ever, be certain that the voltage is low while the 
frequency and the amperage is correspondingly high. 

Technic. — The high frequency machine which I 
am about to demonstrate is of the telatherm type. 
I have used this particular type for several years 
now. It has undergone many changes, and I wish 
to express my appreciation of the cheerful assist- 
ance always offered by the manufacturer in carry- 
ing out the various modifications as time and ex- 
perience dictated. Today we have as a result a 
high frequency apparatus of low voltage and un- 
usually high frequency and a wide range of amper- 
age. Either the diathermia machine, an earlier 
model, or the telatherm, this latest type, answers our 
purpose perfectly. 

The ambulatory patient who comes to your office 
should be treated at least every other day. A strip 
of flexible metal four by eight inches is placed over 
the spinal column and connected with one of the 
binding posts. The other flexible tin, five by six 
inches, is placed across the chest. Before applying 
these electrodes they are moistened with soap lather 
to insure better contact with the bare skin. The 
current is turned on until a meter shows a reading 
of 1500 milliamperes. The average time consumed 
is thirty to forty-five minutes. If no untoward 
symptoms occur after the second week, the current 
is gradually increased to 2000 and later to 2500 
milliamperes, the full output of the machine. 
After the electrodes have been removed the parts 
are sponged with cold water and the patient advised 
to rest for one hour in the recumbent position. 

All cases are divided into first, second and third 
stages. First stage cases should show one hundred 
per cent, cures ; that is, they should be converted 
from open cases into latent ones. During the 
second stage from sixty to eighty per cent, of closed 
cases tnay confidently be expected ; while during the 
third stage only occasionally a case does become 
arrested, nearly all of the patients are made very 
comfortable and their lives prolonged by many years. 
While this short review of so large subject is en- 
tirely inadequate, I hope that the discussion will 
bring out many of the points necessarily omitted. 
301 West Ninety- first Street. 



106 



GRAHAM-MULHALL: EXPERIENCES IN DRUG CONTROL. 



[New York 
Medical Journal. 



EXPERIENCES IN NARCOTIC DRUG 
CONTROL IN THE STATE 
OF NEW YORK* 

By Sara 'Graham-Muliiall, 
New York, 

First Deputy Commissioner, State of New York Department of 
Narcotic Drug Control. 

As adtnini-strator of the First District, which in- 
cludes the Greater City of New York, where drug 
addiction has so focussed that the city is called the 
plague spot of the country, my task has been to 
study intensively a hitherto insoluble problem and 
to interpret and apply the law. My work may be 
classified as both repressive and humanely construc- 
tive. I have secured wholehearted cooperation and 
support from physicians, manufacturers, whole- 
salers, and druggists, in my campaign against the 
misuse of drugs of addiction. The results achieved 
are due in large measure to the success of these ' 
methods of cooperation. The repressive work has 
grown out of the department's supervision of the 
transactions in drugs by certain physicians, regis- 
tered dealers and druggists, resulting in the detection 
of irregularities, frauds and illegitimate practices. 
Some idea of the vastness of this whole narcotic 
problem may be gathered from the following num- 
ber of certificates issued : 



Physicians 10,364 

Apothecaries 4,415 

Wholesalers and manufacturers 286 

Dentists 2,275 

Veterinarians 342 

Institutions and hospitals 336 



MANUFACTURERS AND WHOLESALERS. 

With the exception of medicine prescribed for 
patients by physicians, all orders for narcotic drugs 
involving the purchase or transfer of opium or 
cocaine or their derivatives must be made on official 
order blanks, serially numbered, which may be ob- 
tained from the Department of Narcotic Drug Con- 
trol by registered dealers or users, or by govern- 
ment, public, or private hospitals. The only excep- 
tions to this provision are, first, the permission to 
sell certain exempt preparations without any formal 
blanks, these preparations being remedies and medi- 
cines containing not more than a specified small 
amount of drug not considered dangerous and known 
as the lawful quantity; second, the exemption of 
such preparations as liniments and other ointments, 
which, while containing more than the lawful quan- 
tity, are in such form that the drug cannot be used 
except for external purposes. A record must be' 
kept, however, even of these preparations. 

PAREGORIC NO LONGER EXEMPT. 

Although heretofore exempt, a late ruling has 
.'brought paregoric under control. At Bluefield, 
'West Virginia, in May, 1919, a druggist was found 
guilty of selling paregoric for other than medicinal 
'purposes to an addict, through a second party, for 
several months. The penalty was imprisonment for 
two months or a fine of $200. Through this deci- 
sion the department has been enabled to figlit tlie 
paregoric habit in rural districts. We find that 

•Delivered before the Philadelphia County Medical Society on 
November 10, 1920. 



laudanum and paregoric are sold in large quantities 
by druggists and grocers in rural and suburban 
localities. 

The reports, whicli the law requires at present 
from physicians, manufacturers, wholesalers and 
druggists, include a record of all drugs received for 
local use or distribution, and all drugs sold within 
the state, with the amount, date, name and address 
of purchaser. These thousands of narcotic reports 
are carefully scrutinized, and when violations are 
found, department inspectors are immediately de- 
tailed on the case. This system of control by the 
department has resulted in reducing the amount of 
narcotics distributed by seventy-five per cent. 

In no division of control has greater vigilance 
to be exercised than in that which grants licenses 
to manufacturers and druggists. Reputable manu- 
facturers have from the beginning sent in carefully 
compiled reports which constitute valuable data for 
the department, and in all ways possible they have 
aided the department in the carrying out of the 
antinarcotic act. Since the department has exer- 
cised control over the manufacturers and druggists, 
there has been a great increase in the number of 
those seeking to enter the field of narcotic manu- 
facture. These applications are subjected to rigid 
investigation by the department. How unfit the 
majority of applicants are to be trusted with such 
commercial manufacture is indicated by the fact that 
only ten per cent, of those who apply are granted 
licenses. 

In a number of instances those applying have 
already been granted Federal licenses. In other 
instances applicants upon writing for licenses have 
given addresses that upon investigation are found 
do not exist. In one instance, an applicant who 
thus gave a fictitious address was finally arrested 
and found with $200,000 worth of illegally pro- 
cured narcotics. He was tried and convicted. 
Some of those who apply for licenses are gangsters, 
and some former addicts. A common trick is to 
secure a store or a loft in a busy building, pay, 
rent in advance, and paint the windows so 
heavily with green or black pigment as to render 
them opaque. No furniture is put into the office 
until a license is granted, indicating that they do 
not intend to deal in the manufacture of drugs 
generally, but merely to specialize on narcotics. 
If the license is not granted, the applicants dis- 
appear so that they cannot be traced. 

There has been a great increase in the number of 
applicants for druggists' licenses, showing that the 
activities of the department have stimulated applica- 
tions in this division. Great vigilance is exercised 
over drug stores. While the majority of druggists 
cooperate with the department, some' of them vio- 
late different provisions of the law. These fill 
doctors' prescriptions which are illegally made out; 
others who cater to the narcotic trade have such a 
tremendous rush of business that they do not 
properly care for prescriptions. In one instance a 
drug store, suspected by the department of illegal 
practices, was raided, and thousands of prescrip- 
tions were foimd in the cellar, so that the State and 
Federal officials literally waded in them. It was 
necessary to secure a number of bags and to engage 



January 15, 1921.] GRAH AM -MU LU ALL : EXPERIENCES IN DRUG CONTROL. 



107 



a truck to take these to headquarters. Tlie drug- 
gists encouraged their addict customers to loiter ' 
around their shops, either in the place itself or on 
the adjacent corner. Drugs were the sole topic 
of conversation among these loiterers, who smolced 
incessantly. The department brought the matter tq 
the attention of the druggists and requested them 
not to permit their addict customers to remain in 
the store or in the vicinity longer than to have their 
prescriptions filled, and they were to go home before 
administering it. The addicts were threatened with 
arrest if they continued to make public nuisances 
of themselves. Many druggists were warm in their 
expression of appreciation of the department's vigi- 
lance in this regard. 

THE PHYSICIAN. 

An erroneous opinion in regard to the physician 
has been held by the public, that he is solely respon- 
sible for the spread of addiction. Intensive study 
of the narcotic situation shows unmistakably that 
in ninety per cent, of the cases the addict under 
thirty acquired the habit through bad association 
and home environment, and the middleaged and 
elderly become addicts through selfmedication. 
Experience with thousands of addicts at the clinic, 
through registration procedure, at hospitals and 
with hospital releases, demonstrates that the nar- 
cotic addict is a medical responsibility for ten days 
— during the withdrawal period — after which he 
becomes solely a sociological problem. 

LEGITIMATE PRESCRIBING. 

The only way the addict may obtain drugs legiti- 
mately is through the instrumentality of the phy- 
sician, who may either administer or dispense them 
himself, or write a prescription for them. It is at 
once evident that a very important power is given 
to the physician and that a great deal depends on 
the use he makes of this power. Most physicians 
■ are exercising great care ; others are careless in pre- 
scribing drugs, and some are known to be un- 
scrupulous, using their professional Hcense as 
middlemen in a nefarious practice in the enslave- 
ment of addicts. It is because of these conditions 
that the Department of Narcotic Drug Control has 
had to exercise great vigilance in administering the 
law. This is a very delicate problem, since the 
general purpose of the law is not to add to the 
burden of reputable physicians, but to check those 
whose activities are questionable. 

MISUSE OF THE OFFICIAL BLANK. 

A woman arrives in New York with letters from 
the physicians in her home city, in which it is 
stated that she has a painful facial disease. The 
woman comes under the notice of the department 
when no fewer than four physicians, no one of 
whom knew of the others prescribing, sent reports 
and requests concerning her to the department. It 
appears that when a physician, after prescribing, 
explains to the woman that she must come under 
the law and that he can treat her but once on an 
' unofficial blank, she does not return to him, but 
applies to another doctor, who innocently prescribes 
for her and in turn appeals to the department in 
her behalf, not knowing that she is a peripatetic 
addict. 



Here is an instance where a patient tried to take 
an unfair advantage of the unofficial blank and thus 
escape registration. Unfortunately for her, the 
physicians whom she approached were law abiding 
men, who refused to treat her the second time 
without a certificate, and reported her to the depart- 
ment. 

Another case is that of a hospital orderly who 
was registered as an addict with the department, 
his dose being one grain a day. As his prescrij)- 
tions ceased to come in, an investigation was made. 
It was found that the man had gone to a commercial 
prescribing doctor who knew him to be an addict 
and from him he received prescriptions for four 
grains on unofficial prescriptions. 

The department has uncovered thousands of cases 
of the misuse of the unofficial blank. Such viola- 
tions of the narcotic act have been so flagrant and 
difficult to unearth that a ruling to abolish the un- 
official blank is the only possible method of control. 

EXCESSIVE DOSES. 

When I took office in April, 1919, prescriptions 
of from forty to ninety grains of morphine or 
heroine were frequent. The group of commercial 
narcotic prescribing doctors aggregated in their pre- 
scriptions in one month 1,760,000 grains of narcotic 
drugs. The department early adopted the policy 
of following up such prescriptions, and the pressure 
it brought to bear has resulted in great reductions 
in the amounts prescribed. It is now exceptional 
to find prescriptions calling for niore than ten grains 
of morphine. Cocaitie is restricted to a few grains 
a month, and heroine has been practically eliminated. 

In AJay, 1919, there were in my district sixty-five 
commercial narcotic prescribing doctors. These 
physicians controlled the narcotic situation to a 
large extent. It was unfair that so small a group, 
composed mainly of foreigners, should throw dis- 
credit on the whole medical profession. No time 
was lost in bringing pressure to bear on this group. 
A striking example of the violation of the narcotic 
act was furnished by one of the group. This popu- 
lar narcotic practitioner left the upper sash of the 
basement window lowered. Into this opening his 
hundreds of patients daily tossed their registration 
cards. These were gathered up by his wife and car- 
ried to the doctor. On the morning of his arrest he 
was found by the officers of the law, in bed, in an 
upper story, with the registration cards of forty-five 
of his patients, in which he was busily engaged 
writing prescriptions for addicts whom he did not 
see. It was the custom for his wife to return these 
cards to the patients. Thus he was enabled to se- 
cure a princely income with very little effort. 

Previous to my taking office, one of these physi- 
cians prescribed in one month 68,282 grains of he- 
roine, 54,097 grains of morphine, 30,280 grains of 
cocaine. This same physician after supervision by 
the department prescribed 18,000 grains of mor- 
phine in one month, no heroine and no cocaine. By 
November, 1920, the number of commercial pre- 
scribing doctors in my territory was reduced to 
four, having over twenty-five patients, the highest 
number prescribed for by any of the four being 
a hundred. 



108 



GRAHAM-MULHALL: EXPERIENCES IN DRUG CONTROL. 



[New York 
Medical Journal. 



A startling instance of a doctor prescribing a 
grain a day for an infant shows a sinister phase of 
careless prescribing. This infant was habitually left 
on the sidewalk in a perambulator between 11 p. m. 
and 3 a. m. When the mother was questioned, she 
explained that she was obliged to leave the child on 
the street as she earned her living by cleaning 
saloons and drug stores after 11 p. ni. She could 
not leave the infant at home because she asserted 
that it was an addict and she administered the drug 
to it at stated intervals. This she could not trust 
anyone else to do. As the weather was warm, the 
infant was more comfortable in the open air. I 
wish to emphasize that this infant received a grain 
j\ day on the prescription of a narcotic prescribing 
physician. When the infant was placed in a hos- 
pital under the observation of Dr. L. Emmet Holt, 
the child showed no withdrawal symptoms. This 
infant "was being drugged on the supposition that it 
was an addict because its mother was an addict. 

Another condition requiring control was the un- 
expected result of an order issued July 31, 1919, by 
the then commissioner of the Internal Revenue De- 
partment, Daniel C. Roper. -This order to his sub- 
ordinates stated that the vigorous enforcement of 
the Harrison law must be carried out in such a man- 
ner as not to 'produce unwarranted sufifering on the 
part of the addicts. This was interpreted by the 
commercial prescribing doctors as license to issue 
emergency prescriptions. 

An example of flagrant prescribing is furnished 
by one physician, who wrote eight hundred emer- 
gency prescriptions in one day. Another develop- 
ment of this relaxation of the law was a flooding 
of the department with demands for exemptions by 
the commercial group from the rules and regula- 
tions, until a total of eight thousand were received. 
This entailed careful investigations and medical ex- 
aminations, with the result that only five hundred 
of the applicants were found to be entitled to ex- 
emptions. 

Further study of the situation revealed that the 
addict was being supplied with drugs from many 
sources ; from the prescriptions of physicians legiti- 
mately and also in illegal ways. The first step in 
the control of his drug supply was the establishment 
of a narcotic clinic. The department also ordered 
compulsory registration, appointing the commis- 
sioner of health. Dr. Royal S. Copeland, its agent. 
On July 14, 1919, registration went into ef¥ect un- 
der his supervision. On and after that date every 
addict was required to be registered. When he 
presented himself at the clinic, he was physically 
examined by a physician, after which he received a 
registration card which contained his photograph, 
his name, his address, his age, and his dose sheet. 
Each time the doctor prescribed for an addict, he 
was required to sign a designated blank space on the 
dose sheet for that day, as was also the apothecary 
when filling the prescription. It was hoped that the 
addict would not receive more than one prescription 
for that day because the next doctor or apothecary 
would see that the space on the calendar dose sheet 
for that day had already been signed, and therefore 
would not vfolate the interpretation of the United 
States Supreme Court's decision. Over 7,500 ad- 



dicts were thus registered, which is undoubtedly 
much fewer than the total number of addicts in the 
city. 

The dose sheets served to show, however, how 
commercial prescribing doctors took advantage of 
technicalities under the guise of the ambulatory 
treatment. They accepted at face value the claim of 
the addict as to the amount of drug he required, and 
wrote the figures in such a way as to make forging 
easy. 

Apothecaries who were catering to this kind of 
trade winked at the violations. Counterfeit dose 
sheets soon made their appearance, and were forged 
as to the amount of drug allowed. The extent of 
the violations may be judged by the fact that the 
-^department has a collection of 1,500 counterfeit 
dose sheets, in which the same doctor prescribed for 
the same addict twice a day on each of two such 
dose sheets. The commercial prescribing group 
signed their names illegibly, often with a mere wave 
of the pen, making forging easy, and giving no 
ground for prosecuting the apothecary who accepted 
the prescription ofifered with such dose sheets. 
Again and again the department realized what a 
conspiracy ambulatory practice allowed. 

Under this prevailing practice the addict is com- 
monly treated by what is known as the ambulatory 
method, by which the patient agrees to submit, or 
pretends to submit, to the reduction of his dose 
gradually by a slight amount while going about his 
customary business, in the hope that eventually the 
dose will be so small as to enable the addict to aban- 
don it altogether without serious discomfort. 

Can such a method succeed? It has been shown 
that the craving for drugs is of the most pressing 
and insistent sort; and that enforced abstinence 
produces extreme agony. It has also been shown 
that he cannot be trusted with any considerable 
amount in his possession. Is it not contrary to all 
reason and experience, therefore, to expect success 
from a method by which the addict is asked to un- 
dergo with fortitude and selfcontrol one of the most 
critical stages in the cure of his habit? 

Even those addicts who insist that they are de- 
termined to rid themselves of the habit, after they 
have had the usual dose, change in their mood, lose 
determination and relapse when their supply seems 
to be in danger. Many addicts have had the courage 
to begin treatment under the reduction method, and 
have placed themselves wholeheartedly under the 
care of an honest physician. For a brief time they 
have resisted temptation, and have held out against 
violation of their pledge to rhe doctor while the dose 
was being diminished by very slight amounts. But 
sooner or later, the dose seemed inadequate or 
reached too low a point ; they felt great pain and 
complained of being ill. No restraint but their own 
feeble will, weakened by years of addiction, has 
stood as a barrier to their impulse to relieve their 
sufifering and deceive the doctor. They have bought 
drugs "on the street" or have gone to another doc- 
tor for "treatment" thus doubling their dose. The 
physician soon gets an inkling of this condition, and 
it discourages his hopes of achieving a cure. The 
drug addict thus learns to deceive. 

The consensus of opinion among all those who 



January 15, 1921.] 



GRAHAM-MULHALL: EXPERIENCES IN DRUG CONTROL. 



109 



have given careful study to the problem of drug ad- 
diction condemns this method, as is brought out 
clearly in the report of Dr. E. Eliot Harris, chair- 
man of the Special Committee on the Narcotic Sit- 
uation in the United States, appointed by the Amer- 
ican Medical Association. The large number of re- 
peaters who went to the clinic and to penal institu- 

^ tions gave strong support to this view which con- 
demns the ambulatory method of treatment. The 
clinic was organized for the humane purpose of sav- 
ing the addict from the profiteering doctor and the 
profiteering druggist and to prepare him for hospi- 
talization. Addicts received their medicine at whole- 
sale prices and they had every attention. They came 
Fy thousands when they found that they could get 
the drug for very little money and without doctors' 

• . fees. The first day the clinic was opened, cocaine 
was dispensed, but it was stopped on the second day, 
no cocaine being again dispensed there. The chief 
drugs sold were heroine and morphine, ninety per 
cent, of the addicts who came to the clinic being 
heroine users, who acquired the habit through bad 
association. All classes attended the clinic — the un- 
derworld, the criminal, respectable men and women, 
including physicians, clergymen, nurses and actors. 
The addict was started on the maximum dose of fif- 
teen grains, regardless of whether he had formerly 
received thirty or seventy grains (these being the 
average doses prescribed for thousands of addicts 
throughout the city). Thereafter the dose was reg- 
ularly reduced in accordance with the decision of 
the United States Supreme Court. Demoralization 
set in and the addicts became discontented. 

As the third step in control, a hospital at River- 
side was opened and when the addicts reached the 
irreducible minimum, they were compelled either to 
go to the hospital or were refused further doses at 
the clinic, the monthly dose sheet being then denied 
them. At this period in the history of the clinic we 
lost sight of thousands of addicts. The number of 
prescriptions issued will give some idea of what the 
work entailed, some days over two thousand pre- 
scriptions being issued. As the dose became smaller, 
the demoralization grew. The constant reduction of 
• the dose incensed the addict and he resorted to petty 
larceny — stole pocketbooks. fountain pens, any 
small saleable object that he could lay his hands 
upon. He also lied and forged in order to obtain 
additional drug. 

The majority of the addicts who patronized the 
clinic were of the underworld type and the respect- 
able men and women who were compelled to go 
there through poverty were soon demoralized, their 
addresses were secured and they were followed to 
their homes. Peddlers openly plied their trade in 
the clinic in spite of six supervising policemen. 
When one peddler more daring than the others was 
arrested, another immediately took his place. In the 
course of time the addicts were shut out of the 
lavatories and retiring rooms which had been as- 
signed to them to selfadminister the drug, as they 
grossly abused these privileges. The addicts then 
resorted to an adjacent park where in the open air 
and before groups of school children, they applied 
the hypodermic needle and generally conducted 
'themselves in an unseemly manner. The scenes be- 



came so scandalous that petitions were sent to the 
Governor of the State and to others calling for the 
suppression of these demoralizing daily exhibitions 
by the closing of the clinic. 

Within a period of eleven months the clinic had 
run its course. It had failed as a clearing house for 
the hospital, had become a profitable market for 
peddlers, and the socalled reduction method failed 
to cure any addicts. It was only through the author- 
ity the department imposed upon them, supple- 
mented by moral suasion, that even so few as 2,800 
of the 7,700 registered addicts were induced to go to 
the hospital. The narcotic clinic stands out as an 
enormously expensive and colossal failure. The 
third step in attempted control was the hospital. 

The experiment was made with a municipal hos- 
pital, where the treatment was scientific and skill- 
ful, which resulted in ideal conditions for the short- 
term hospital experiment. The full treatment there 
was for a period of six weeks only. Patients in all 
stages of physical condition, undernourished, drug 
saturated, highly nervous, or deadened by narcotics, 
were received. These were each subjected to a pre- 
liminary treatment suited to the needs of the indi- 
vidual. 

Quoting Dr. Braunlich in charge of this muni- 
cipal hospital : "The marked abstinence symptoms 
on withdrawal of the drug are selflimited to seven- 
ty-two hours. After the drug has been withdrawn 
and the addict has passed through the mild hyoscine 
treatment, he finds himself in the convalescent build- 
ing. Although he is much weakened, he is able to 
be up and around, but because of his muscular 
weakness and his sleeplessness, he is at his worst as 
to his craving for the drug. This is the danger 
period for the addict and it is during this time that 
he needs the most careful watching and medica- 
tion." At this hospital those in charge administered 
at this period hypnotics such as bromides, veronal, 
and chloral. Within another week the patient was 
sent from the convalescent ward to the dormitory 
building where he was given suitable work. He 
received no more medicine of any kind except for 
some intercurrent afifection. 

Among all convalescent addicts a peculiar state 
of mind exists, a craving for the drug which per- 
sists even after its withdrawal. The tendency of 
the mind is to revert to narcotics and this becomes 
more pronounced if the former addict knows how 
to get the drug or has hoped to get it. Dr. Braun- 
lich states that if the patient has any hope of getting 
the drug during the six weeks' period of treatment, 
he will undoubtedly relapse into his old habit. 

The addicts when discharged from the hospital 
showed an average increase of from twenty-five to 
forty pounds in weight. Peddlers and fellow ad- 
dicts met the hospital discharges on the New York 
boat landing and tempted them with an oflfer of free 
drugs under the guise of good fellowship. Of those 
who withstood the first onslaught, a percentage suc- 
cumbed when they returned to their old neighbor- 
hoods and met the boys and their former narcotic 
physicians. We have demonstrated that the muni- 
cipal short term hospital, although administering a 
benign and effective cure, has been conceded by all 
those in charge as lacking in the scientific feature of 



110 ' GRAHAM-MULHALL: EXPER 

classitication. Criminals, defectives, the tubercu- 
lous, the moral and the immoral, and those whose 
only weakness was drug addiction, were accepted 
indiscriminately. This is a serious defect of the 
short term hospital and is largely responsible for 
the number who are buying drugs on the street. 

When the department took office it found that 
the addicts were generally despised and without 
either officials or laymen to plead that they be treated 
humanely. It was assumed without basis of fact 
that the addict was a wilfully vicious creature who 
refused to abandon his habit although he could do 
so if he would'. Acting upon this theory the courts, 
the police and the jail keepers treated him as a de- 
> spicable creature who merited only severe treatment 
and this was usually accorded him. Even the court 
forms for voluntary commitments to hospitals were 
couched in punitive terms. The department has 
materially modified these hard conditions. 

New York city was peculiar iji its form of drug 
addiction, as over ninety per cent, of its drug users 
were addicted to heroine, the most baneful, the most 
powerful of habit forming drugs, and the most de- 
trimental in its effect upon the user. It is cheap, 
because it demands neither lay out nor hypodermic 
svringe, and can be taken for some time without 
disturbing the health ; it stops the craving without 
diminishing the working capacity to a degree which 
would prevent the earning of money to buy the 
drug. It is sniffed through the nose on a quill, and 
the addict can take heroine without fear of being 
detected or being interfered with. This drug has 
developed a distinct clas^ with a certain amount of 
freemasonry and cooperation among themselves, 
which is necessary to make it easy for users to pro- 
cure heroine and also to safeguard one another in 
the indulgence of a practice forbidden by law. The 
majority of the heroine users were young_jnen 
whose easy sociability developed into gangs. In 
their leisure hours they flocked together in dance 
halls, pool rooms, roller skating halls, and movies. 
For some time the boys remain in good health and 
possess a fair degree of intelligence. Because of 
their youth they lack individual initiative, are imi- 
tative and easily led, and fall into the habit easily, 
the tragic part being, ignorantly. Once the habit is 
festablished, interest is lost in work. The addicts 
become late and irregular in their hours of work 
and finally they throw up their positions. Many are ' 
good workmen, but they only work long enough to 
**>procure money with which to buy the drug. 
^ • On March 6, 1920. the department instituted *a 
•' moral drive against the prescribing of heroine. The 
' cooperation of doctors and druggists was asked 
through every possible means of communication, 
they being requested to substitute morphine for he- 
roine all along the line. The response was cordial 
and prompt, and within forty-eight hours from the 
/time the signal was given to the first doctor, heroine 
was taboo in the Greater City of New York. I am 
in receipt of many letters from both physicians and 
addicts warmly thanking me for the order. The 
improvement reported is a lessening of nervousness, 
improvement in appetite, and restful sleep, an expe- 
rience many of them had not enjo\'ed for many 
months. 



ENCES IN DRUG CONTROL. ^A^^"^' Y""*" 

Medical Journal. 

Dr. B. reports: "It gives me pleasure to inform 
yoU' that your ruling eliminating heroine has been a 
blessing in disguise to many addicts. The first few 
days were a nrghtmare to both the addict and the 
physician ; however, as soon as the systems of the 
addicts adapted themselves to the new drug (mor- 
"phine) very few complained, in fact at least ten 
openly expressed their happiness at the change. Do 
not let anyone tell you that an addict cannot 
let heroine alone, and don't let any one tell you that • 
he will die. I think you made a glorious move in 
doing what vou did (attack on heroine) March 8, 
1920." 

Now it is rare for the department to receive 
a physician's prescription calling for even the small- 
est amount of heroine. As you probably know, he- 

. roine is being sent into China to a considerable ex- 
tent, large amounts being exported from this coun- 
try. The heroine habit there is taking the place of 

^the far less dangerous vice of opium. 

It is not always the perversion of the social in- 
stincts alone that is responsible for the creation of 
new addicts. Among those interested in such gangs 
are the illicit peddler, the smuggler, and the traf- 
ficker, whose commercial motives result in the en- 
slavement of new victims. In its most vicious 
]ihases, the power of dispensing the much prized 
drug is one of the surest ways for a "Fagin" to hold 
his pupils or a white slaver to maintain control over 
his prey. 

Peddlers, like drug addiction, flourish in centres 
of large or congested population. True to the name, 
the peddler has no store or permanent place where 
he carries on his trade. He may take up his stand 
at a certain street corner or in the middle of a block 
for a day, possibly a week, after which he will move 
to a position a mile or two away in the same city, or 
even move to another city. The smuggled drug is 
jiot, however, the peddler's sole source of supply. 
He will often finance the drug addict. As an illus- 
tration, the addict may be too poor to pay for a doc- 
tor's prescription, or to pay the druggist for filling 
it. The peddler will give him the necessary money, 
it being agreed between them that when the addict 
procures the dn;g he will divide ijt with the peddler. 
A peddler who thus finances from twenty to fifty 
drug addicts will obtain not only a fair supply of 
the drug, but reap a material profit on his initial 
outlay of money, for he sells the drug at a rate in 
excess of that charged by the druggist, and he adul- 
terates it in order to make it go further, the most 
used substance for adulteration being sugar of milk, 
or some other article sufficiently white to resemble 
the drug. I have known of instances where the ad- 
dict who had paid at the rate of a dollar a |j.rain 
would get six tenths of a grain, and many more 
instances where he would be sold nothing but pure 
sugar of milk. I realize that this will naturally 
cause the question to be asked, Why then does the 
addict buy from the peddler? There are three 
answers : The hesitation of having his addiction 
known to the authorities, as it would be if treated 
by a doctor or at a clinic; the inclination to satisfy 
his craving by illegitimate means, and the fear of 
having his dose reduced by the doctor or the clinic. 

The speedy elimination of the narcotic peddler is 



January 15, 1921.] 



GRAHAM-MULHALL: EXPERIENCES IN, DRUG CONTROL. 



Ill 



the object of a plan I submitted to Commissioner 
Enriglit, of the New York PoHce Department, a 
plan which he accepted. It called for the creation 
of a special narcotic corps with a criminologist, who 
is also a physician, at the head. This corps supple- 
ments the Federal, State and Municipal narcotic 
agents and its special duties will be the detection 
and arrest of illicit peddlers. The physician whom 
I suggested as head of the corps had been for more 
than a year in charge of the department's clinic, 
where by special orders he was permitted to study 
the conditions and histories of thousands of addicts, 
also the policies and future plans of the department. 
This cooperation between the State narcotic depart- 
ment and the municipal police has resulted in a 
vigorous campaign against the peddler. I have also 
enlisted the cooperation of the State constabulary, 
the chairman of which is Dr. Lewis Rutherford B. 
Morris, for the outlying cities and towns of my dis- 
trict. With these aggressive bodies continually on 
their trail, the peddlers will soon realize that New 
York is no longer an open town. 

My appeal is now in behalf of 22,000 registered 
narcotic addicts, together with unnumbered thou- 
sands in this State, who are neglected and shunned 
by the public. The following facts are pregnant 
with meaning: 

1. The addict cannot free himself. 

2. He needs institutional custodial care to relieve 
him permanently of his habit and to rebuild him 
spiritually, mentally, and physically, so that he can 
be returned to society an asset. 

There is no gainsaying these statements. What 
provision do the State and the city make to meet 
adequately these desperate needs? New York city 
closes its hospitals — Bellevue, Metropolitan, Kings 
County, and the remaining hospital. Riverside, is 
being run on a three weeks' schedule instead of one 
of six weeks as heretofore. Its present capacity is 
from fifteen to twenty-five, formerly a capacity for 
800. The patients are now released when they are 
psychologically and physically unprepared to be sent 
back to their old environment and its temptations. 
The results of this short term hospital emphasize 
the fact that such limited treatment is a waste of 
time and money. 

The United States Government has fully recog- 
nized that addiction is a country wide problem, but 
it has only emphasized the punitive attributes of the 
Harrison antinarcotic law rigidly enforced. This 
is the crux of the whole situation. Due to these one 
sided measures of attack, this problem has remained 
unsolved because the Federal Government has thus 
far failed to recognize that the humane attitude and 
the law enforcement attitude are antagonistic and 
nullify each other unless united, as they should be 
in a great State institution for the proper custody, 
care and cure of the addict. The same argument 
holds good for the several States. 

The initial step in this combination of effort is 
the establishment of institutions where the addict 
can be properly cared for on the institutional colony 
plan, which admits of segregation of the several 
classes and employment in the arts and crafts and 
fanning. Such institutions should be under medical 
direction. 



Under a plan for commitment of drug addicts, 
the State institutions can be used for the permanent 
reclamation of these unfortunates. After the ad- 
dict is taken oft' tlie drug, he will be placed under 
the observation of experts for classification. 

Class I : Those who suffer from a disease or 
ailment recjuiring the use of narcotic drugs. 

Class II : Addicts are those who use narcotic 
drugs for the comfort they afford and solely by 
reason of an acquired habit. 

Class II may be subdivided into : a, correctional ; 
b, mental defectives; c, social misfits; d, fortuitous 
(occurring by chance). 

For those who are found to be true defectives, 
the State institution will not be the proper place, as 
institutions are already in existence for the care of 
mental defectives, where they are segregated and 
made as useful as possible. Among the correctional 
cases there will probably be worked out certain sub- 
classes. Those who are true criminals will be sent 
to other institutions. There will also be borderline 
mental cases which can be industrially reclaimed and 
returned to the world, if kept under the supervision 
of a wise probation system. The true cases for this 
colony life will be found among the social misfits, 
who will find here their great chance to make the 
start in life that they never had, under such direc- 
tion as will assist them to find their proper place. 
Such a life will also be of the greatest benefit to 
those who are normal except for their drug addic- 
tion. 

The present is full of hope because we have 
found, upon investigation and experiment, that the 
drug addiction problem is soluble. To begin with, 
the average age of the addicts is only twenty-four 
years. We have brought the general public to a 
realization of the extent and the menace of drug 
addiction which it now knows transcends in serious- 
ness the much discussed alcoholism, and this 
awakened public opinion can be relied upon in the 
future to support all worthy measures designed to 
relieve this country of drug addiction. In spite of 
the failures of the clinic and the short term hos- 
pital, they have served the useful purpose of point- 
ing the way to the only possible solution of drug 
addiction, that is. the State narcotic institution on 
the colony plan, for the rehabilitation of the addict, 
physically, mentally, and morally. The department 
is grateful to the members of the medical profes- 
sion for the cooperation extended in the past, and 
it looks forward to their cooperation and help in 
the future. 

Lithiasis of the Urinary Organs.— I. S. Kolb 
(Urologic and Cutaneous Review, May, 1920) 
concludes Aat there is no surgical procedure 
fraught with more serious sequelje than litholapaxy. 
It has its limited indications, but is more properly 
controlled by contraindications. These latter are 
very large calculi, very hard calculi, and infected 
bladders. Small vesical stones in the absence of a 
marked cystitis should be removed by crushing, 
with a proviso that the operator be experienced and 
skillful in the manipulation of the lithotrite ; other- 
wise it is far better for the patient to have a supra- 
pubic cystotomy. 



112 



MEDICAL SOCIAL SERVICE. 



[New York 
Medical Journal. 



MEDICAL SOCIAL SERVICE IN 
DISPENSARIES * 

By the Public Health Committee of the New York 
Academy of Medicine. 

( Concluded from page 69.) 

IX. AGENCIES REFERRING PATIENTS TO SOCIAL 
SERVICE DEPARTMENTS. 

Of the 675 cases studied, 170 came to the several 
social service departments referred there by clinic 
doctors ; 201 were sent from within the various in- 
stitutions from sources other than clinic doctors, 
and of these, forty-four, or 6.5 per cent, of the 
entire group of new cases, were picked by the social 
workers themselves; 175 came to the social service 
through outside agencies. Of this division, schools, 
settlements and relief societies referred eighty-one, 
or 12 per cent, of all cases; private physicians re- 
ferred twenty-four, or 3.6 per cent, of all cases, 
while thirty-seven, or 5.5 per cent., came by per- 
sonal application to the attention of the social ser- 
vice departments. For 129, or over 19 per cent, 
of the patients, the source of the original reference 
was not designated. The large number of cases 
regarding which no information is available as to 
their initial direction indicates that the entries in 
the records are not complete. 

The clinic grouping of patients referred to the 
social service departments shows that 22.7 per cent, 
were under care in the children's clinics, 22.2 per 
cent, in the tuberculosis clinics, 11.4 per cent, in 
the cardiac clinics, 7.4 per cent, in the general 
medical clinics, over five per cent, in the gyneco- 
logical clinics, and practically the same percentage 
in the poliomyelitis clinics ; twenty-two per cent, 
were distributed among the other departments of 
the institutions, and the clinic connection for the 
remaining 4.1 per cent, of cases could not be ascer- 
tained from the records. 

X. PURPOSES FOR WHICH PATIENTS WERE SENT TO 
THE SOCIAL SERVICE DEPARTMENTS. 

An effort was made to obtain information from 
the records as to the reasons and purposes for 
referring patients to social service departments, in 
order to determine what the functions of social serv- 
ice are considered to be by those who refer the cases, 
and by reason of such reference accordingly become. 
We find that 52.7 per cent, of all the cases are 
referred for what may be broadly termed medical 
aid in the form of cHnical examinations (when 
cases are referred from outside agencies), for 
hospital, sanatorium or convalescent care, for 
special treatment, for nursing, or for recreation 
and rest. Eleven and one tenth per cent, were 
referred for relief of one kind or another ; 7.6 
per cent, were referred for instruction with regard 
to the condition of the patient, the mode of 
life, or the care of children; 7.9 per cent, were re- 
ferred for an investigation, either with regard to 
the home situation or the financial status of the 
patient, or with regard to the occupation. Only 

*This constitutes a part of the report on th- Dispensary Situation 
in New York City by the Public Health Committee of the New 
York Academy of Medicine, of which Dr. Charles L. Dana is chair- 
man. Dr. James Alexander Miller is secretary, and E. H. Lewinski- 
Corwin, Ph. D., is executive secretary. 



0.9 per cent, were referred to have suitable employ- 
ment found for them, 2.2 per cent, for family re- 
adjustment to render treatment possible, 9.4 per 
cent, for general supervision, and in 8.2 per cent, 
of the cases reasons were not stated. 

The greatest variety in the social service activities 
is observed in application to patients of the pedi- 
atric, tuberculosis and cardiac clinics. These three 
departments also show the largest numbers of social 
service cases. Taking the group of 356 patients 
referred for medical aid, we find that 32.4 per cent, 
of them were referred for a clinic examination, 
over half being in the tuberculosis department; 
twelve per cent, were in need of hospital care ; 13.7 
per cent, needed convalescent care; eight per cent, 
were in need of special treatment, and twenty-two 
per cent, needed stimulation in order to make them 
come back to the dispensary, the bulk being children 
in the pediatric, poliomyelitis and cardiac cHnics. 
A small number needed home nursing, and a few 
patients were referred to the social service depart- 
ments in order that examination in other clinics 
might be obtained or that opportunities for rest or 
recreation might be provided. 

Among the seventy-five patients referred for 
financial aid, 54.6 per cent, were in need of appa- 
ratus for special treatment; 6.6 per cent, were in 
need of funds to obtain the special diet prescribed, 
and 38.6 per cent, needed general relief, belonging 
economically to the substandard group. In fifty-one 
cases referred for instruction, 23.5 per cent, needed 
explanation of their condition, 33.3 per cent, instruc- 
tion as to diet and general hygiene, and 43.1 per 
cent, education in the care of children. Among 
the group designated as "referred for investigation" 
in thirty-eight instances was the home situation 
specified as needing special attention. The other 
fifteen cases were referred for investigation of 
financial status to determine whether the patients 
had claims on dispensary aid, all of them, however, 
belonging to one institution where specialties are 
treated. 

To ascertain how clearly the cases were under- 
stood by persons referring them, a table was pre- 
pared comparing the purposes for referring cases 
with the social service problem as it developed after 
investigation had been made. Of the 356 cases 
referred for medical care, in only 217, or about 
sixty-one per cent., was medical care found to be 
the chief problem. Of the remaining thirty-nine 
per cent, of the cases, thirty-two per cent, needed 
home instruction, 1.9 per cent, needed family re- 
adjustment, 0.8 per cent, needed employment, and 
4.3 per cent, needed financial assistance. 

Similarly, among the seventy-five patients re- 
ferred for financial assistance, fifty-four or seventy- 
two per cent, required such help; 14.7 per cent, 
needed medical aid, 2.7 per cent, needed employ- 
ment, 1.3 per cent, needed family readjustment, 
eight per cent, required home instruction, and in- 
vestigation showed that in 1.3 per cent, of the cases 
outside assistance was not desirable. 

Among the patients referred for educational pur- 
poses, 66.6 per cent, or thirty-four of the fifty-one 
required that as their main aid. The remaining 
thirty-three per cent, divided itself as follows: 5.9 



January IS, 1921.] 



MEDICAL SOCIAL SERVICE. 



113 



per cent., financial help; 13.7 per cent., hospital 
care; 3.9 per cent., clinic care; two per cent., em- 
ployment ; 3.9 per cent., family readjustment, and 
in 3.9 per cent, investigation showed no problem 
needing social care. From this it can be seen that 
the workers freely change the plan of care • after 
investigation has shown the case to be diflferent than 
as at first supposed. In this respect medical social 
work differs from home nursing. In the latter, the 
nurse follows medical directions and is not free to 
change the procedure without the sanction of the 
doctor, while in the medical social work the i)erson 
referring the case leaves the plan of action entirely 
to the judgment of the worker. 

XI. SELECTIOX OF PATIENT. 

The discussion of the achievements and failures 
of medical social work suggests the question as to 
the point in dispensary routine at which the social 
service department should begin to function. Should 
it wait until the patient has made actual contact 
with the clinic physician, or should it be the first 
to receive him? With few exceptions the usual 
practice is for the patient to come to the attention 
of the social service department only after he has 
passed through the clinic, and the facts about his 
disease have been developed and medical treatment 
prescribed. The first contact of the patient is with 
the registrar, who may or may not be an agreeable 
person. The patient then proceeds in his turn to 
the Avaiting room, where he may wait as long as 
an hour or more. Then his turn comes to go into 
the clinic. There he is interrogated rapidly, his 
examination made and treatment given . or pre- 
scribed as quickly as possible, and he goes out, 
probably without having had a real opportunity to 
become adjusted to an unusual situation. 

It is generally recognized that one of the most 
important elements of successful functioning of the 
dispensary is the establishment of proper relations 
with the patient at the outset by giving him a proper 
understanding of the dispensary's responsibility to 
him and his responsibility to the dispensary, and 
that this could properly come within the scope of 
the social service department in the case of all new 
admissions. A great deal of the now wasted effort 
on the part of the physicians and the loss of time 
and energy on the part of patients could be obviated 
by humanizing the initial contact. 

In one of the large special institutions of New 
York, which has not a full fledged social service 
department as yet, the experiment has been tried 
out with a corps of visiting nurses and several 
volunteers whose duty it is to interview patients 
after they have registered. They take all the pre- 
liminary history and the patient is given an oppor- 
tunity to state his circumstances. All of this occurs 
in a room sufficiently large to obviate the un- 
pleasantness of telling one's story within the hear- 
ing of fellow patients. Not only does this result 
in securing better histories and in obtaining an 
immediate understanding of the patient, but it 
permits the patient to become adjusted to the dis- 
pensary easily and gradually. Anyone who has 
observed the smoothness with which this dispensary 
operates cannot fail to appreciate the importance 
of this method. 



The financial information concerning the patient 

called for by the representation card and the social 
facts of the medical history could be elicited to 
advantage by workers of the social service depart- 
ment if arrangement were made to have every 
patient pass first through the admission office of 
the department. This information would ftirnish 
the physicians with the important facts concerning 
each patient and afford to the social service depart- 
ment an opportunity of gauging the social problem 
of the dispensary in its entirety, and to select for 
its endeavor such cases as most need it or would be 
most likely to profit by its assistance rather than 
to leave entirely to the preoccupied physicians the 
designation of cases needing investigation or guid- 
ance. As has been shown above, physicians take 
a markedly differing degree of interest in social 
service work. Some refer many patients, others 
very few or none. It is in justice to the patients 
that a degree of freedom should be left to the 
social service departments as to the selection of 
cases, and also in justice to the department itself. 
With a given personnel and a given amount of 
funds only a certain amount of work can be done 
effectively. As to that the department itself is 
the best judge. 

XII. RELATION OF SOCIAL SERVICE DEPARTMENT 
TO SPECIAL CLINIC SERVICES. 

The question of assignment of social workers to 
special clinics is another important consideration. 
Because of their magnitude, or because of the par- 
ticular problems involved, certain departments, such 
as tuberculosis, venereal diseases, or pediatrics, re- 
quire the exclusive services of social workers. In 
the determination of the assignment of social 
workers, however, more is involved than the qtian- 
tity of social service work needed in an individual 
clinic. 

If the dispensary is to be regarded as a training 
ground for social workers, then the necessities 
of such a training course must also be taken 
into consideration and an opportunity should be 
afforded for a working acquaintance with all fields 
of dispensai^y work in which social service has 
proved to be a most important factor. The deter- 
mination of such fields should not be based, as is 
often done, on the special interest or special de- 
mands of the clinic physician. When a physician 
has an appreciation of or interest in social work 
he may, and often does, make demands upon the 
social service department far in excess of its 
capacity; if he is not interested in social work, even 
though his clinic may offer a very fertile field for 
it, he may make no demands upon the social service 
department. 

Determination of special clinic needs should 
be based upon a comprehensive survey of the 
entire field rather than upon the surface indica- 
tions of the demands of clinic physicians, and such 
a survey of the entire field is quite possible when 
the social service department has the initial contact 
with the patient, as has been suggested. 

In the social service departments studied, the ten- 
dency to assign special workers to certain clinics is 
marked, for in thirteen of the fifteen dispensaries 
in which children's clinics are maintained, social 



114 



LONDON LETTER. 



[New York 
Medical Journal. 



service workers were found. In all of the dis- 
pensaries having tuberculosis clinics, social service 
workers are stationed in the clinics. Four of the 
five dispensaries having cardiac clinics depend on 
the assistance of a special social worker. In two 
institutions special workers have charge of the 
poliomyelitis work, and two general outpatient de- 
partments have special prenatal workers. One of 
the institutions has a worker devoting her time to 
a vaginitis class. These workers are usually ex- 
pected to help in the medical treatment as well as 
to direct the social care of the patient. 

XIII. A SOCIAL SERVICE CLEARING HOUSE. 

Few dispensaries limit their services to patients 
drawn from a definite territory. . It is well nigh 
impossible to do so for a great many reasons, one 
being the shifting of the patients. To deny a 
patient admission to a dispensary which he had 
formerly attended simply because he had moved to 
a different section of the city is at times difficult; 
l)Ut unquestionably there is a great deal of time lost 
by social service departments in following up patients 
who live at some distance from the dispensary. 

The Maternity Centre Association established 
several years ago, which has as its object the develop- 
ment of standard equipment, practice and records 
in the maternity clinics of the city, as well as the 
development of an adequate centrally supervised 
home visiting service, offers a suggestion which may 
be of value particularly to the social service depart- 
ments of dispensaries. Provided standard methods 
and record forms could be adopted by dispensary 
social service departments, such a central clearing 
house for social service work could be extremely 
valuable for the dispensaries in a given large district 
in which there are several dispensaries, if not for 
the city as a whole. The patient who is remote 
from a particular dispensary could very readily be 
referred to the attention of a social service depart- 
ment near his home. Reports from one social 
service department to another could readily be 
exchanged through this central clearing house, or 
referred directly from one department to another, 
but the chief object of the clearing house would be 
to provide the patient with social service ^id quickly 
and economically, and in accordance with the de- 
mands of medical treatment in the dispensary where 
he receives attention. 

It is suggested that such an experiment, although 
fraught with difficulties, would be at least worth 
trying. A number of hospital social service depart- 
ments in a given area might pool their social serv- 
ice work and cooperate with other outside agencies 
interested in the social service problem. Central 
control could be established under a competent direc- 
tor for the entire district, in headquarters con- 
veniently located within the district. All hospital 
and dispensary social service workers as well as 
workers from outside agencies would be placed 
under the control of this district director, and all 
demands for social service would pass through such 
a director's hands, assignments for followup being 
made as required. Reports of work done should 
be returned to the office of the director and, when 
approved, transmitted to the proper institution. 



LONDON LETTER. 
(From our own correspondent. I 
The Ministry of Health Bill. 

London, December 21, ig^o. 

On, November 5th Dr. Addison, the Minister of 
Health, moved the second reading of the Ministry 
of Health Bill. Referring to the treatment of 
mental disorders, he pointed out that during the war 
a system had been set up whereby men suffering 
from shell shock and affections of that kind, who 
were mentally disordered for a short period, had 
received mental hospital treatment, so that they 
never became classed as lunatics, and thereby 
escaped any disabilities which their mental state 
might have brought upon them. The experience 
of the war was clearly one of which use ought to 
be made, and provision was made in Clause 10 of 
the bill for the continuance of this form of treat- 
ment, under very stringent safeguards for all cases 
of this class. The bill provided that persons so 
treated must be suffering from mental disorder 
incipient in character and of recent origin. Treat- 
ment in respect of any individual case would be 
limited to six months. It was. necessary to erect 
all possible safeguards so as to prevent any scandals, 
such as the detention of people against their will 
or anything of that kind. Some said the safeguards 
were too stringent, but these points could be raised 
in committee. The best course was to have a suc- 
cessful experiment on a small scale without any 
scandals and difficulties. 

The minister now came to the proposal in the 
bill which might involve an increased burden on 
the rates. None of these he had so far discussed 
would do so. The question of assisting the volun- 
tary hospitals from the rates had 'aroused much 
criticism. He had seen the headhne "Hospitals 
on the Rates." That was not the proposal of the 
bill. It was obvious that at no time of our history, 
and certainly not up to the time of the experience 
of the war, was it wise or practicable to ignore a 
real and earnest public necessity. Nothing could 
be more shortsighted. The fact was that up and 
down the country the accommodation in voluntary 
hospitals was unfortunately insufficient to meet 
public needs. He thought everyone would agree 
that anyone who suggested at the present time, if 
by any means it could be avoided, that the voluntary 
hospitals should come upon the rates, would be 
either seriously irresponsible or worse. 

The facts of the case were these : With the 
assistance of the ofificers of the Ministry of Health 
and those of the Red Cross, the financial position 
of the hospitals for some years past was examined, 
that is, of the voluntary hospitals. It appears that 
during the five years 1913-18 there was a deficit 
on the provincial hospitals in respect of excessive 
expenditure over income of £1,300,000. So far 
as London voluntary hospitals are concerned, the 
deficit in round figxires amounted to £900,000. 
During this time these hospitals received a number 
of free legacies not earmarked for particular beds 
and so on. He therefore thinks it is quite fair to 
ask the hospitals in the present emergency to see 
tliat these free legacies are u.sed to relieve ordinary 



January 15, 1921.] 



LONDON LETTER. 



115 



expenditure. If the free legacies of both London 
and provincial hospitals were taken into account 
they would balance the expenditure over the five 
years mentioned. Unfortunately, however, some 
of the voluntary hospitals were more fortunate than 
others. With the increased cost of food, wages, 
maintenance, and so on, unfortunately the expendi- 
ture falling on voluntary hospitals had risen much 
more than the income. There the discrepancy 
between the two was greater than it had been. 

Again, it had to be remembered that many of 
those who had been accustomed to subscribe to the 
voluntary hospitals had been very badly hit by the 
war. For that reason, and because of taxation, 
they had found it exceedingly difficult to maintain 
their contributions and still less to increase them. 
The class which was colloquially known as the 
middle rich did not seem yet to have learned to 
subscribe to voluntary hospitals in any extensive 
way. Accordingly, the cooperation of the King- 
Edward Hospital Fund was sought, and those 
in charge of that fund had set aside out of their 
accumulated reserve a sum of £250,000 to assist the 
London hospitals. The King Edward Hospital Fund 
being limited in its. operations to London, negotia- 
tions with the National Relief Fund took place, and 
that fund had set aside the magnificent sum of 
£700,000 to help the voluntary hospitals. 

There was a proposal in Clause 2 of the bill which 
enabled local authorities, if they so desired, to 
make voluntary contributions to hospitals, but in 
this there was nothing new. So far as the volun- 
tary hospitals were concerned, they were not 
affected, except that an authority might make a 
voluntary contribution. But the pressure on the 
hospital accommodation of the country could not 
in any case be met by the efiforts of the voluntary 
hospitals. There were in the country 45,000 beds 
in general and special hospitals, mostly maintained 
by subscriptions, but there were 94,000 general 
hospital beds under the poor law maintained out 
of the rates. Thirty thousand poor law beds were 
empty, while voluntary hospitals were crowded, 
and had enormous waiting lists ; hospitals main- 
tained out of the rates had a large number of empty 
beds. He suggested that some practical scheme 
should be devised to make use of good bed accom- 
modation where it existed. There were two sets 
of objections, the professional and that of the rate- 
payer. 

The hospital system is in a state of chaos. 
Practically every institution, whether endowed or 
not, is begging for money to carry on, while the 
directors of some, notably of the London hospital 
in the East End of the metropolis, state unreserv- 
edly that unless large amounts are quickly forth- 
coming their doors must be closed or, at least, a 
part of the institution cannot continue its beneficent 
or rather essential work. All are agreed that 
nationalization or even municipalization of hospi- 
tals is undesirable and the majority wish for a 
continuation of the voluntary system. But if 
sufficient funds are not forthcoming, how is such 
a course possible? The Minister of Health states 
that the King Edward Hospital Fund has given 
$1,250,000 and that the National Relief Fund has 



donated $3,500,000 which will tide the voluntary 
hospitals over their immediate difficulties. 

After all, this is merely tinkering with the prob- 
lem and does not reach the root. Sir George 
Newman in his masterly work The Outlines of Pre- 
ventive Medicine points out that the solution does 
not lie in collecting money alone but in a thorough 
reorganization of the entire hospital system of 
Great Britain. However, while this statement is 
absolutely true, what body is going to undertake this 
reorganization and unification? The Ministry of 
Health is unable to do so at the present time. This 
department is choked by superabundance of serious 
health problems. It has nolens volcns, to use an 
American expression, "bitten off more than it can 
chew." In the meantime the hospitals are going 
from bad to worse. The voluntary system is im- 
bedded in the hearts of the British public. Its 
traditions are magnificent and if it could be ade- 
quately supported it might be for the best for all 
concerned to -maintain the system. There are many 
who say that if those who ought to contribute to 
the support of the hospitals according to their means 
thus contributed all would be well. Yet people 
cannot be pestered into giving, however subtle and 
convincing the propaganda may be. The newly 
rich, especially the individuals who have made for- 
tunes out of the war, no doubt, as Dr. Addison said 
in the House of Commons, have acquired the repu- 
tation of expending large sums in ostentatious 
display but have not acquired the habit of giving 
to charity. It is to be hoped that their duties and 
responsibilities, so far as charity is concerned, may 
soon be impressed upon them. The working classes 
who now earn three, four or five times more money 
than they earned before the war and who receive 
free treatment give with a niggardly hand to these 
institutions from which they receive the most benefit. 

Is there then a way out of the difficulty which 
will avoid nationalization or municipalization and 
placing more heavy burdens on the already over- 
burdened ratepayers? There must be and one mode 
has been suggested by some, namely, to introduce 
the pay system or partial pay system. Let everyone 
pay according to his or her means and while this 
may not be a complete solution, it appears that it 
will be going a long way in this direction. The 
working classes can now afiford to pay and, in fact, 
are in a better position to do so than the middle 
classes who are mulcted in rates to an almost un- 
believable extent. It seems that the general intro- 
duction of a pay system would relieve the 
immediate necessities of the hospitals, would do 
away with a great deal of abuse of these institutions 
by those who can afford to pay, would provide 
efficient medical and surgical treatment to the poorer 
ratepayers and would tend to self respect and inde- 
pendence on the part of all who seek the services 
of hospitals. The Ministry of Health cannot do 
everything and with regard to the hospitals can 
only give advice and assist to a limited extent. In 
the last resort the salvation of the people in health 
as in other directions, rests largely with the people 
themselves. However, the Ministry of Health and 
the medical profession generally can and should 
point the way. 



Editorial Notes and Comments 



NEW YORK. MEDICAL JOURNAL 

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NEW YORK, SATURDAY, JANUARY 15, 1921. 



MEDICAL RESEARCH. 

Scientific research and perhaps medical research 
especially are greatly exercising the minds of mem- 
bers of the medical profession and citizens in 
general. The man in the street has a very hazy 
idea of what medical research is and what it signi- 
fies and if he were told that it was the foundation 
stone of preventive medicine and, correctly inter- 
preted and intelligently applied, led to health, he 
would wonder what kind of nonsense he was being 
told. The inner significance of medical research is 
fully cotnprehended by the few only. The public 
require education on the subject before the value of 
medical research will be evident to the majority, and 
therefore it seems essential that such education 
should be freely profifered. If there is one man of 
the English speaking world who is conscious of the 
value of this form of research it is Sir Almroth 
Wright, and consequently when he discourses on 
the subject one may rely upon hearing something 
well worth while. 

On November 11, 1920, Sir Almroth Wright was 
presented with the gold medal of the Royal 
Society of Medicine and took the occasion to make 
comments upon medical research and the conditions 
indispensable to the achievement of new knowledge. 
He said in part that the compilation of details was 
within the power of every intellect ; the great need 
in medicine at present was for more genetic 
generalizations. For this a special type of intellect 
was needed, and even then such generalizations 
could only be arrived at slowly and as a result of 



much study. Having arrived at a generalization 
the next necessary step was to verify it. Four out 
of every five generalizations believed and accepted 
by men were wrong, and nine out of ten believed 
by women. The scientific worker was the man 
with a scientific imagination who afterward knew 
how to verify. The man who made a genetic .sug- 
gestion did not advance things unless he devi.sed a 
means of testing it and had the skill to carry it out. 
Experiment was the intellectual machinery for doing 
this. The layman or quack could not do it. In 
sliort, the man successful in medical research must 
in the first instance possess imagination ; the pains- 
taking plodder is unable to think out anything 
original. 

Bvit, in addition, the imaginative man engaged 
in scientific research, medical or otherwise, should 
be so trained that he can ascertain the value of his 
ideas by the acid test of experiment. Sir Almroth 
argued that, because the laboratory worker was 
the sole person who could test his results directly 
by experiment, he was in a better position than 
anyone else, even the physician, who had to allow 
time to elapse in order to learn results. From this 
reasoning he drew several important conclusions. 
If a hospital had no laboratory men at hand to 
ascertain the effects of its treatment, advance could 
scarcely be expected. Attached to every hospital 
there should be a laboratory research stafif, whose 
function it should be to test new things, to make 
generalizations, and to extend knowledge by subse- 
quent verification. 

Stress was laid by the speaker on the need for 
fully trained men to do laboratory work. Labora- 
tories not attached to ho.spitals did not turn out good 
work, as the stimulus of fresh inaterial from hos- 
pitals was lacking. He insisted that men who 
entered upon a career of research should have a 
l^ermanent job, with an increasing salary. Lastly, 
he urged that the only person who could direct men 
to do useful research was one who knew the neces- 
sary methods from having himself been engaged in 
such . work. A surgeon or physician who had not 
had this training had no rightful place on the direct- 
ing stafif. The higher workers of the laboratory 
stafif should be given a due share or voice in direct- 
ing the policy. Assuredly the president of a re- 
search organization should not be a busy politician 
or any other layman ; he should be a person eminent 
in science and whose energies were engaged in 
connection with science. 

There is little to cavil at in the exposition of 



January IS, 1921.] 



EDITORIAL ARTICLES. 



117 



what is required as to personnel and organization 
of a medical research staff. Perhaps too great 
emphasis is laid on the role of the laboratory worker 
and too little on the part played by the clinician. 
Surely laboratory tests by experiment are some- 
times fallacious and, at any rate, clinical tests, 
although they may be slow, are reliable. Of course, 
the ideal plan is for the clinician and laboratory 
man to work in harmonic conjunction and it cer- 
tainly is essential, if the obscure features of disease 
are to be traced to their innermost lairs, that a well 
equipped, well staffed laboratory should be attached 
to every large hospital. It is also obvious that with- 
out imagination the research worker will never go 
far, and, of course, he should be thoroughly trained. 

No man should be a director of a laboratory un- 
less he knows his work from alpha to omega, and 
an active politician should be barred from holding 
any such position. The public should be educated 
to appreciate the benefits to be derived from 
medical research work, and the work itself should 
be carried on in the manner sketched by Sir 
Almroth Wright. If this comes to pass, and there 
is no reason why it should not, the results of 
medical research work, the discovery of the causes 
of disease, may ultimately banish the greater part 
of the diseases which now oppress and handicap the 
inhabitants of the world. However, if this end is 
to be reached medical research must not be ham- 
pered for lack of funds, and the community at large 
must cooperate to aid its advancement. 



WHAT EXERCISE IS BEST 
"You need more exercise!" How often the ad- 
vice is given without specification as to how, when, 
where or under what conditions the exercise is to 
be taken. And what, after all, do we mean by exer- 
cise and what exercise is of most benefit? 

By exercise, unspecified, we usually have in mind 
the active, conscious, use of the voluntary muscles, 
and often our thought goes no farther. These can- 
not be made to work, however, without exercise of 
the nervous machinery, and, accompanying and fol- 
lowing the activity of the voluntary machinery, 
there are sundry changes (exercise) of the invol- 
untary nervous, muscular and glandular apparatus. 
In fact, voluntary muscular exercise means an in- 
creased activity of all structures of the body. 

But the mere purposeless waving of arms, kick- 
ing of legs or even so complicated a performance as 
walking, after it can be done without conscious 
effort, does not mean that the person is receiving the 
maximum of benefit. It has even been asserted that 
routine exercise done in a perfunctory fashion does 
more harm than good. It is especially the mental 



side of the human being that must be taken into ac- 
count in exercise for health, for, unfortunately, 
while the lower levels of the nervous mechanism may 
be engaged in directing muscular movements, the 
higher ones may be at work in such fashion as to 
counteract the good results of the muscular move- 
ments. The patient is early fatigued and wonders 
why his benefit is so slight. 

The degree of mental occupation thus becomes 
a test of the value of exercise for purposes of 
health. Mental work is always accompanied by 
some, and often by great, activity of the other 
mechanisms of the body, which does not show on 
the surface. The driving of a motor car, which, 
if not mental, is accompanied by continuous coor- 
dinate use of muscles all over the body, and with 
a fairly constant attention of the mental machine. 
Boerhaave understood this vital principle for bene- 
ficial exercise when he advised the obese gentleman 
from Amsterdam, that, if he wished to be treated by 
him, he must come to Leyden on foot. The wonder 
and curiosity aroused by such an order which must 
have filled the mind of the rich patient when it was 
not absorbed in the passing scenery, made it pos- 
sible for him to carry his unwieldy body the dis- 
tance, and, by the time he had completed his journey, 
the cure was well on the way to accomplishment and 
was lasting. A wise American physician was in the 
habit of advising his clients with little to do, to pur- 
chase a dog and to take daily outings in its com- 
pany. The dog was of course for the purpose of 
objective mental absorption. 

The work of teaching, primarily nervous exercise, 
is accompanied by a vigorous activity of the whole 
machine. The muscles become tense, the heart beat 
quickens, and the blood pressure rises. When the 
pupils respond in kind and there is no distraction 
from the work in hand teaching can hardly be other 
than healthful. Unfortunately these conditions are 
rarely present, two things must be attended to at 
once, introspection is mixed with circumspection, 
and the former, as worry, is carried over for constant 
nerve leakage in after school hours. Under such 
conditions the exercise of teaching becomes weari- 
some, wearing and anything but beneficial, and the 
only help in the case is to seek other occupation. 
Exercise to be most beneficial must, then, be some- 
thing more than mere calisthenics — something more 
essential than mere muscular contractions and re- 
laxations but should be some occupation, it matters 
little what, in which the machine works as a whole 
and with self forgetfulness. It is the mental side 
which must be looked to first in prescribing exercise, 
the mere muscular performance is of minor import- 
ance, save that the latter should be fitted to the 
strength and endurance of the exerciser. 



118 



EDITORIAL ARTICLES. 



[New York 
Medical Journal. 



HEMATEMESIS AND VARICOSE VEINS 
OF THE ESOPHAGUS. 

Hematemesis is one of the principal symptoms in 
certain diseases of the esophagus, stomach and duo- 
denum, gastric ulcer being probably the most fre- 
quent cause of the vomiting of blood. In ulcer of 
the stomach this is preceded by nausea, while in 
diseases of the esophagus the blood is vomited with- 
out any preceding malaise. Duodenal ulcer may 
give rise to hematemesis, but it is less common in 
this affection than melena. During the evolution of 
hepatic cirrhosis blood may be vomited, and this is 
usually attributed to varicose veins of the esophagus, 
but even when abundant and repeated the hema- 
temesis may take place without the existence of 
varicose veins of the esophagus, or if these do exist, 
without ulceration. On the other hand, varicose 
veins of the esophagus may develop without cirr- 
hosis of the liver. Lastly, in hemophilia very severe 
vomiting of blood may occur. 

Hematemesis ofifers two distinct types, according 
to whether the blood has been retained in the 
stomach or is expelled at once. In the latter case it 
is fluid or coagulated, but easily recognized as blood. 
When it has been retained in the stomach it under- 
goes digestive changes, and is vomited in the form 
of small, blackish lumps. The black transformation 
of blood in the stomach depends upon two factors, 
namely, the amount of blood and the length of time 
it has been in contact with the gastric juice. A 
severe hematemesis gives rise to all the symptoms 
met with in profuse hemorrhage, but slight, re- 
peated hematemesis may lead to anemia. 

The esophagus has a rich supply of veins, arteries 
and lymphatics, and is innervated by the pneumo- 
gastric and a few branches of the sympathetic. The 
venous network receives its blood from the portal 
vein, which from its anastomoses communicates 
with the caval system. From the viewpoint of the 
etiology of esophageal varices, some observers adopt 
the same classification as for hemorrhoids, namely, 
those having a mechanical cause, and secondly, the 
constitutional or idiopathic type. In the first class, 
the process may be due to temporary compression, 
while permanent compression results from diseases 
of the portal vein, or hepatic processes, particularly 
cirrhosis, dilatation of the stomach, and lastly, 
diseases of the spleen and heart, especially lesions of 
the mitral valves, and esophagitis. Esophagitis, 
whether acute or chronic, is more prone to occur at 
the upper portion of the tube, the lower and middle 
portions being less commonly involved. Ulcers de- 
velop and may occasionally give rise to purulent 
foci, the former often contributing to rupture of 
the varicose veins present. 



Varicose veins of the idiopathic type are due to 
rather complex causes, such as climate or plethora, 
while heredity plays a considerable part in the 
etiology. When the cause of the varix is temporary, 
as in pregnancy, phenomena of congestion appear, 
but are usually mild, and after labor has taken place 
the process disappears. When the cause is a per- 
manent one, the congestion is likewise, although a 
spontaneous cure is not impossible. On the other 
hand, idiopathic varix is marked by intense con- 
gestive phenomena, with or without hemorrhage, 
and, if this is repeated frequently, anemia and 
digestive and cardiovascular disturbances occur. 

The outcome of the process may be recovery, but 
usually it becomes chronic, and the evolution is sub- 
ordinated to the occurrence of complications. Death 
may occur from hemorrhage or some intercurrent 
affection. 



PHYSICIAN AUTHORS: DR. JAMES BALL 
NAYLOR. 

One of President-elect Harding's closest per- 
sonal friends is Dr. James Ball Naylor, of Malta, 
Ohio, who, in addition to being a practising physi- 
cian, also has been for the past seven years a special 
editorial writer on the staff of Senator Harding's 
newspaper, the Marion (Ohio) Star, and is an 
author of nationwide reputation, with seven novels, 
three books for children, one book for boys, and 
four books of verse to his credit — besides many 
short stories, special articles, and campaign songs. 

Of course, Dr. Naylor is in politics, too. It is next 
to impossible for an Ohioan to keep out of politics. 
"I play the game of politics because I like it," says 
Dr. Naylor, "not with the expectation of reforming 
the people, and not because of the hope of reward. 
I aspire to no seat among the mighty. I simply 
desire to live my own life, in my own way, to my 
own satisfaction. If I can do a little good every 
day in so doing — well, so much the better." It was 
through politics that he and Senator Harding became 
acquainted, during the campaign of 1910 when 
Harding ran for Governor of Ohio and Dr. Naylor 
was the Republican candidate for State Senator of 
his home district. Both were defeated. During 
the course of the campaign they spoke from the 
same platform on numerous occasions and a warm 
friendship sprang up betwen them that has con- 
tinued ever since. When Senator Harding was 
elected to the United States Senate in 1914 he chose 
Dr. Naylor to take his place as the writer of leaders 
for the Star. Dr. Naylor coupled this work with 
his medical practice and continued to reside in 
Malta, where he has practised ever since he got his 
medical degree at Starling Medical College, in 



January 15, 19-' I.) 



EDITORIAL ARTICLES. 



119 



Columbus, Ohio, in 1886. Malta is but a few miles 
from Pennsville, Ohio, where Dr. Naylor was born 
on October 4, 1860, and so great is his affection 
for the quiet little Ohio village, and so strong his 
dislike of city life — even such mild city life as is 
aflforded in Marion — that no temptations have suc- 
ceeded in weaning him away from it. "1 like the 
country; I dislike the city," says Dr. Naylor. "I've 
spent days in New York, Boston, Chicago, Cleve- 
land, Columbus, and other cities, but I've always 
been glad to get away from them and back to the 
rural solitudes." 

It may readily be guessed that Dr. Naylc^r took 
a very active 'part in the recent campaign which 
resulted in the Harding landslide. He has taken 
pan in every campaign in Ohio for the past thirty 
years, but it was natural that in this last campaign, 
with a personal friend running for the Presidency, 
his political enthusiasm should be keyed up to its 
maximum pitch. Paraphrasing the old adage, ap- 
parently Dr. Naylor's motto is, "Let me write the 
songs of a campaign and I care not who makes the 
speeches," for he has written probably more cam- 
paign songs than any other living man, and they 
have been first class ones, too. If there are any 
who doubt Dr. Naylor's skill along this line, it is 
only necessary that they peruse the pages of the 
Republican Campaign Songbook for 1920, issued 
by the Ohio State Republican Executive Committee, 
and be convinced. The book is largely the work of 
Dr. Naylor, and gives ample proof of his consum- 
mate cleverness in such work. They are rollicking 
songs, for the most part written to fit the tunes of 
Casey Jones, A Hot Time in the Old Tozvn, Long- 
Boy, and such like droll ditties, full of irony and 
ridicule designed to make a laughing stock of the 
opposition and to inspire enthusiasm and faith in the 
ticket and cause espoused. Some are in a more 
sober vein, however, as if to keep a proper emotional 
balance and adjustment, and carry such staid airs 
as those of America and The Battle Hymn of -the 
Republic. But whether blithesome or serious, Nay- 
lor's campaign songs always have a touch of inspired 
fervor about them, and this was particularly true 
of his efiforts during the recent campaign. 

Naylor's four volumes of poetry show him to be 
capable of some very gracefully turned verse full 
of homespun optimism, lively humor, and love of 
his fellowman. He sings of those homely themes 
that are close to the heart of that class of reader 
who knows what he likes and likes it so well that 
he clips it out and carries it around in his pocket, 
or else pastes it in a scrapbook. They are poems 
of simple appeal, of the James Whitcomb Riley 
type, but with less emphasis on the uncouth. In 



them Naylor touches deftly upon all those humble 
little phases of life which go to make up the exist- 
ence of the commonalty of the rural sections of the 
Middle West. They are the verses of a natural 
poet whose heart is flowing over with sung, and 
they are a refreshing relief from the stilted erudi- 
tion that marks so much of the poetical product of 
today. Naylor's novels include The Sign of the 
Prophet, The Kentiickian, a vividly told story of 
Ohio life in Civil War times ; The Misadventures 
of Marjory, the story of a young, vivacious and 
audacious heroine of the desperately willful type; 
Under Mad Anthony's Banner, a tale of the War 
of 1812; TJie Scalazvags, hi the Days of St. Clair, 
a Middle West historical novel, and The Cabin in 
the Big IP'oods, a stor}' of pioneer Ohio life. 

Dr. Naylor was educated in the public schools of 
Ohio and at Marietta College, Ohio, after which he 
attended Starling Medical College. "I'm sixty years 
old according to the records, but I'm 600 years old 
when it comes to varied experiences, and I'm 6,000 
years old when I come to count the mistakes I've 
made and the blunders I've committed," he says. 
"I'm a Yank, not a cosmopolite; an American, not 
a world citizen. I'm at home where my heart is, 
not where my hat's off^. And my creed is : 

When my country's in the right 
I'll defend her with my might ; 
When my country's in the wrong 
I'll help to set her right ere long. 
But whether right, or whether wrong, 
I've just one love — I've just one song: 
My country ! 

"I like dogs and children. I'm the father of six 
children, all living and grown, and the grandfather 
of five. Yet I can still live, and love and laugh. 
I write prose as a duty or a task ; I write verse for 
the joy of it. When I write prose I live on Grub 
Street ; when I write verse I dwell in Paradise 
Alley." 

Except for his editorials, however, Dr. Naylor is 
not writing a great deal these days. The editorials, 
his medical practice, and the office of District Health 
Commissioner of Morgan County, Ohio, leave him 
little time for anything else. 

NASAL STASIS. 

Lord Chesterfield, whose good manners none may 
doubt, told his son not to use his handkerchief at 
table, but to rise and go to a window, turning his 
back to the company. He does not say anything 
about that irritating, persistent, discordant habit of 
sniffing. It begins at an early age, sometimes 
through nonprovision of a handkerchief, or ignor- 
ance of how to use it, though there is the sniffs of 
laziness, making it a substitute for what is termed 



120 



XEli'S ITEMS. 



[New York 
Medical Journal. 



— a good blow. The siiifif of contempt or incredulity 
is not due to nasal stasis and no handkerchief, be it 
ever so large, or fine, or perfumed, will spare friends 
the exasperation of hearing it. 

Children in their desire to keep their airways 
free sniff away any excess of discharge away from 
the main currents. The semifluid mass in the nos- 
trils is constantly drawn in and is, finally, difficult 
to remove. Perpetual sniffing, with no wholesome 
outward blowing, makes the nose an effective incu- 
bator. As the majority of diseases are air borne, 
the condition of stasis is one of danger. It may 
also lead to chronic catarrh o{ the mucous mem- 
brane owing to the irritation produced by the 
foreign material present. After having ascertained 
that the nose is normal, careful and patient atten- 
tion to the overcoming of bad habits may render 
the person or child an unobjectionable member of 
society. 



ALOPECIA AND TEETH. 

It is a custom now to refer to every research in 
science, art or religion as a field. In many of these 
fields the fence has been broken down and permits 
of cattle and other animals straying, particularly 
when they can prove a theory or adorn a fact. A 
pure bred Holstein-Friesian bull strayed calmly 
into the field of dentistry. The veterinary had noted 
him to have defective front teeth and such teeth 
had an intimate connection with alopecia in the 
human. So the trespasser was watched, and, al- 
though his brides were as pure bred as himself, 
three of five calves had deficiency in teeth, with 
baldness on the head and neck, though hair was 
not entirely lacking. Two other calves had bald- 
ness, though their teeth were norma! in appearance. 
We believe there is a dentist attached to the staff 
of every zoo. When the dental clinic is in every 
village, attention must be turned to establishing a 
zoological one ! 

<$> 

News Items. 



Mineola Home for Cardiac Children. — The 

committee in charge of this fund announces that 
$20,000 was collected last week on the opening day 
of the drive for $100,000 to establish a home for 
chronic cardiac children at Mineola, L. I. 

An Epidemic of Hiccoughing in Budapest. — It 
is reported that an epidemic of hiccoughing in Buda- 
pest, which the physicians are unable to con- 
trol, is causing alarm, although as yet there have 
been no fatalities. It is believed by some medical 
authorities that this hiccoughing is a forerunner of 
influenza. 

To Abolish State Narcotic Commission. — Gov- 
ernor Miller, in his message to the New York State 
Legislature, suggested that the State Narcotic Com- 
mission be abolished. Health Commissioner Royal 
S. Copeland has expressed his approval of the pro- 
posal as he believes that the campaign against drug 
addiction can be handled by the health authorities. 
Dr. Copeland said that in his opinion the drug addict 
should be treated in a hospital, not a clinic. 



Suicides in Budapest. — According to dispatches 
from Budapest, cold and hunger are causing an 
average of fifteen suicides daily in that city. 

Aid Association, Philadelphia County Medical 
Society. — At the recent annual meeting of this 
society the following officers were elected : Presi- 
dent, Dr. E. E. Montgomery ; vice-president, Dr. 
James M. Anders; treasurer. Dr. John B. Turner; 
secretary. Dr. J. Leslie Davis; directors. Dr. J. 
Solis-Cohen, Dr. William M. Welch, and Dr. P. 
Brooke Bland. 

New Radio Call for Doctor.— "K D K E" is the 
new wireless call which is to be used by ships at 
sea to indicate that someone on board is seriously 
ill and that expert medical advice is needed. Medical 
officers are to be kept within reach of the Navy 
department radio to answer calls so that they will 
be able to diagnose and prescribe by wireless when 
their assistance is sought. 

Society of Industrial Medicine Organized. — 
The Wisconsin Association of Industrial Physicians 
and Surgeons was organized recently, its member- 
ship consisting of the physicians and surgeons em- 
ployed by industrial corporations of Wisconsin. Dr. 
Clare E. Schram, of Beloit, is president ; Dr. Robert 
A. Waite, of Milwaukee, vice-president, and Dr. 
Robert E. Fitzgerald, of Milwaukee, secretary- 
treasurer. 

Dr. Friedman's Turtle Serum. — The Berlin 
Medical Society recently held eight meetings for 
the purpose of discussing the value of Dr. Frederick 
F. Friedman's turtle serum in the treatment of 
tuberculosis, but failed to reach a decision that was 
acceptable to the membership of the society. Fur- 
ther experimentation was advised. This serum was 
investigated for more than a year by the United 
States Public Health Sen'ice, but was discredited 
in 1913. A bitter fight for and against Dr. Fried- 
man has raged in German medical circles since the 
discovery of the cure was announced. 

Public Health Service Activities. — The Vene- 
real Disease Division of the United States Public 
Health Service has received an appropriation of 
$200,000 for the next fiscal year. The amount 
asked for was $336,715. The Bureau asked for 
$50,000 for health education and $200,000 for the 
control of influenza and other epidemic diseases, 
but the request was not granted. The sum of 
$80,000 is provided for the maintenance of a home 
for lepers at Carville, La. An appropriation of 
$50,000 was granted for the control of biological 
products. 

Association for Research in Nervous and Men- 
tal Diseases. — At the first annual meeting of this 
association, held in New York on December 28th 
and 29th, Dr. Walter Timme was elected president, 
Dr. E. W. Taylor, vice-president, and Dr. Foster 
Kennedy, secretary-treasurer. A commission on 
scientific research was appointed, composed of the 
officers, ex officio, and the following members : Dr. 
Charles L. Dana, of New York ; Dr. William G. 
Spiller, of Philadelphia: Dr. Hugh T. Patrick, of 
Chicago-; Dr. Bernard Sachs, of New York; Dr. 
Israel Strauss, of New York ; Dr. Lewellys F. 
Barker, of Baltimore, and Dr. J. Ramsay Hunt, of 
New York. 



January 15, 1921.] 



NEWS ITEMS. 



i21 



Red Cross Health Work. — Chief among; the 
activities, during the past year, of the Health Serv- 
ice of the American Red Cross Society, organized 
about a year ago by the Atlantic Division of the 
society, was the establishment of seventeen health 
centres in New York State, six in New Jersey, and 
three in Connecticut, and the inauguration of vari- 
ous phases of health service in sixty-one other places 
in the division. 

Increase in Alcoholic Insanity in Chicago. — 
Cases of insanity from alcoholism have increased in 
the Cook County Psychopathic Hospital since pro- 
hibition went into effect, according to the quarterly 
report of Dr. James Whitney Hall. Dr. Hall re- 
ported an increase of thirty-three per cent, in alco- 
holic cases in December, 1920, over the same month 
last year, and of sixteen per cent, in November. 
A slight increase was noted in October over previous 
Octobers, while in September the increase was thirty 
per cent. 

Mental Disease Among War Veterans. — The 

Joint Committee for Aid to Disabled Veterans states 
that the estimated number of veterans of the world 
war suffering from mental and nervous disorders 
is 76,688. Twenty thousand of these are now in 
hospitals, and medical authorities say that during 
1921 at least thirty thousand will need hospital 
treatment. The report shows that in New York 
State 845 veterans suffering from mental and nerv- 
ous disorders are being treated in thirty-nine 
institutions. 

Cornell University Endowment Fund. — Cornell 
University's semicentennial endowment fund 
amounted to $8,952,770 at the close of the campaign. 
The total represents gifts from 10,114 former Cor- 
nellians, or thirty-two per cent, of all Cornell alumni 
and former students, and 408 other persons who 
had not attended the institution. The sum of $6,- 
243,917 will be used for the purpose of increasing 
professor's salaries, with the exception of one gift 
of $500,000 for the endowment of research. The 
remainder comprises gifts for buildings and im- 
provements, including two principal items of $1,500.- 
000 for a new chemistry laboratory and $500,000 
for the Medical College in New York city. 

Meetings of Local Medical Societies. — The fol- 
lowing medical societies will meet in New York 
during the coming week: 

_ Monday. January ijth. — New York Academy of Medi- 
cine (Section in Ophthalmology) ; Medical Association of 
the Greater City of New York (annual) ; Psychiatric So- 
ciety of Ward's Island ; Yorkville Medical Society. 

Tuesday, January iSth. — New York Academy of Medi- 
cine (Section in Medicine); Federation of Medical Eco- 
nomic Leagues (annual). 

Wendesday, January igth. — New York Academy of 
Medicine (Section in Genitourinary Diseases) ; Medico- 
legal Society; Northwestern Medical and Surgical Society 
of New York ; Woman's Medical Association of New 
York; Alumni Association of City Hospital. 

Thursday, January 20th. — New York Academy of Medi- 
cine (stated meeting) ; New York Celtic Medical Society. 

Friday, January 21st. — New York Academy of Medicine 
(Section in Orthopedic Surgery) ; Clinical Society of the 
New York Post-Graduate Medical School and Hospital ; 
New York Microscopical Society ; Alumni Association of 
Roosevelt Hospital ; Brooklyn Medical Society. 

Saturday, January 22nd. — Harvard Medical Society; 
Lenox Medical and Surgical Society ; New York Medical 
and Surgical Society ; West End Medical Society. 



Red Cross Relief for Children in Europe. — The 

executive committee of the x\mcrican Red Cross 
has appropriated $5,000,000 from the society's re- 
serve fund to furnish medical assistance for children 
in Europe. Dr. Livingston Farrand, chairman of 
the central committee of the Red Cross, in making 
this announcement, said that this work must not be 
confused with that of feeding the several millions 
of children in Europe who are not diseased but are 
threatened with starvation. The general feeding 
problem is being handled by the Europe Relief 
Council, composed of eight organizations. 

Personal. — Dr. Robert P. Bay has been ap- 
pointed a member of the Board of Supervisors of 
City Charities, Baltimore, to succeed Dr. J. Whit- 
ridge Williams, resigned. 

Dr. Roger S. Morris has resumed his work in the 
College of Medicine of the University of Cincinnati, 
after a year's leave of absence. 

Dr. Henry Cuthbert Bazett, Cheselden Welsh lec- 
turer of clinical physiology at the University of 
Oxford, has accepted the chair of physiology in the 
Medical Department of the University of Pennsyl- 
vania. 

Professor A. B. Macallum, of McGill University, 
Montreal, will leave for the Orient in March, to 
deliver a course of lectures, extending over a period 
of seven months, at the medical college in Peking, 
China. 

<^ 

Died. 

Bartlett. — In New York, on Wednesday, January 5, Dr. 
William Allen Bartlett, aged sixty-three years. 

Conrad. — In Glendale, Cal., on Saturday, December 25th, 
Dr. Andrew O. Conrad, aged fifty-three years. 

Farnham. — In Almond, N. Y., on Thursday, December 
30th, Dr. L. D. Farnham, aged ninety-one years. 

Glass. — In Beech Bottom, W. Va., on Tuesday, Decem- 
ber 21st, Dr. Montgomery Walker Glass, aged sixty-seven 
years. 

HoRNE. — In Anderson, Ind., on Tuesday, December 21st, 
Dr. William N. Horne, aged sixty-seven years. 

Jack. — In Hornell, N. Y., on Friday, December 31st, Dr. 
Harvey P. Jack, aged fifty-five years. 

Jacobs. — In New York, on Thursday, December 30th. Dr. 
Louis Jacobs, aged thirty-nine years. 

KiNGSMAN. — In Washington, D. C, on Friday, December 
31st, Dr. Richard Kingsman, aged sixty-six years. 

Knipe. — In New York, on Wednesday, January 5th, Dr. 
George Knipe, aged sixty-three years. 

Leonard. — In Broome Center, N. Y., on Sunday, Decem- 
ber 26th, Dr. Duncan M. Leonard, aged eighty-three years. 

McFadden. — In Buffalo, N. Y., on Thursday, December 
23rd, Dr. James J. McFadden, aged seventy-one years. 

McLaughlin. — In Washington, D. C, on Monday, Jan- 
uary 3rd, Dr. Thomas Notley McLaughlin, aged fifty-nine 
years. 

Messenger. — In New York, on Wednesday, January 
5th, Dr. Joseph E. Messenger, aged sixty-seven years. 

Schweitzer. — In Reading, Pa., on Sunday, December 
26th, Dr. Richard S. Schweitzer, of Adamstown, aged 
sixty-eight years. 

Swift. — In Castle Creek, N. Y., on Tuesday, December 
28th, Dr. Charles L. Swift, aged seventy-one years. 

Woodbury. — In Clifton Springs, N. Y., on Thursday, 
January 6th, Dr. Malcolm Sumner Woodbury, aged forty 
years. 



Book Reviews 



MEDICAL GYMNASTICS. 

Medical Gymnastics in Medicine and Surgery. By E. 
Bf.llis Clayton, M. B., B.C. (Cantab.), Director of the 
Physiotherapeutic Department, and in Charge of the 
Massage and Electrical School, King's College Hospital, 
London. New York : Longmans, Green & Co. : London : 
Edward Arnold, 1920. Pp. viii-159. 

The title is somewhat alarminfj until the nurse 
and doctor find it is not purposed to introduce 
calisthenics or acrobatic feats into daily treatment. 
In fact, a great many of the exercises are vicarious, 
for they include massage, passive movements, 
petrttssage, kneading, stroking, effleurage. 

But, some say, all this a competent massetise is 
supposed to know. Yes, the mechanical side, but 
does she know when to abstain? The one who 
understands the conditions underlying treatment is 
invaluable, the pure mechanician is a constant source 
of anxiety to the doctor. Those who do not know 
will be greatly helped by a pertisal of the book, 
those who do know will be surprised to find how- 
much they have forgotten, or how mtich they have 
acquired through intelligent practice. 

General pathology and principles of treatment 
stand on the threshold, then these various divisions 
are spoken of: skin, muscles, fractures, joint dis- 
eases, deformities, circulatory diseases, respiratory 
diseases, the genitourinary and the nervous system, 
concluding with a scheme of exercises and principles 
of reeducation. 

By the printer's aid, mtich wading through imi- 
form type is saved. The disease and its various 
forms are given, then their catises, symptoms and 
treatment, each heading in different type. A warn- 
ing is given to distinguish between voluntary and 
involuntary movements, particularly in spastic cases, 
because the latter do not mean recovery but exag- 
gerated reflexes. The popular idea that massage is 
simply a mixture of indiscriminate rubbing, knead- 
ing and stroking shrinks away with all this 
knowledge revealed. 

INDIGESTION. 

Textbook of Indigestion. By Dr. G. Herschell. Revised 
and Rewritten by Adolph Abrahams, O. B. E., M. D. 
(Camb.), M. R. C. P. (London), Assistant Physician to 
Westminster Hospital, to the Hampstead and North- 
western General Hospital, etc., etc. New York : Long- 
mans, Green & Co. ; London : Edward Arnold, 1920. Pp. 
228. 

The laity have a wonderful atlas of their own 
devising in which the topography of the stomach is 
somewhat vague. A small boy came to a London 
dispensary with a mother made diagnosis. It said, 
"Bil 'as stumik ake," and Bil rubbed his hand over 
the lower part of the belly ; on which part hot cloths 
are usually put when ordered for the stomach. By 
the help of the same atlas, a person will press his 
hand over the stomach and say his heart is troubling 
him. But, nowadays, doctors are allowing patients 
to learn through x ray plates and flttoroscopy, and 
elderly nervous patients, who have taken every 
aperient they could get, are annoyed to find their 
doctor putting more emphasis on quiet mentality, 
good company and pleasant food than on some pill 
or powder. 



Why a fourth edition? Well, in that of 1905, 
organic diseases of the stomach were not specially 
dealt with, nor the great advance in radiology and 
our conception of functional disease. The reviewer 
has rarely met a book so clear or comprehensive. 
It does not minimize the slight pains of the neuras- 
thenic nor draw gloomy pictures of those organically 
diseased. He admits a certain immtmity to foods. 
How the rich man and the laborer might exchange 
dinners and both be very ill in conseqttence. That 
the indigestion may result not from the food, but 
from mental causes or environment or hurry : the 
contents of one meal in the stomach not being got 
rid of before another is ptit in. Tea and toast, muf- 
fins and hot cakes inctir his wrath when taken as 
an adjunctory meal, or early morning tea preceding 
breakfast only by an hour. The other day the re- 
viewer saw a tachyphagic fiend ptit away a bowl of 
soup, a meat pie and cofifee in three minutes, while 
his neighbor with rusks and fruit carefully munched 
and munched in a -style most Gladstonic. There is 
a time table giving the approximate time in which 
dififerent articles of food should leave the stomach, 
so the dyspeptic can see that his eggs and bacon 
leave the stomachic depot when his train leaves for 
town. 

The chapter on Nervous Digestion teaches what 
to avoid and that on Food Recipes will make obedi- 
ence a pleasure. Carefully read, the patent medicine 
man will have to close his store and seek a place 
which possesses no copy of Herschell and Abra- 
hams. 

Lives of rich men all remind us. 

They can't make their lives sublime. 
For the stomachs attached to them 

Keep them doping all the time. 

BACKWATERS OF LETHE. 

Backivaters of Lethe. By G. A. H. Barton, M. D., .Anes- 
thetist to the Hampstead General and Royal National 
Orthopedic Hospital, etc. Illustrated. London : H. K. , 
Lewis & Co., 1920. Pp. v-151. : 

This English author is cordially invited to cross j 
the Atlantic where he will find with his colleague, j 
Professor Leonard Williams, that "medicine need | 
not be dull as well as difficult." The fact that he j 
has crystallized his own wide experience for the 
use of beginners in his own cheerftil fashion, deal- 
ing with those small matters usually omitted in 
textbooks, will ensure him a welcome from all 
sttidents here. The reviewer recalls the far away 
times at the Society of Anesthetists, when the for- 
mality, in contradistinction to American ways, was 
only softened by cofi'ee and cake, and where, as a i 
newly fledged reporter, he made Dudley Buxton i 
produce necrosis instead of narcosis, and his con- 
sequent dodging of the irate speaker. 

What is the lure of anesthetics? asks Barton; 
not in the easy work, for the dental student should 
be well versed in the laws of heat, mechanics of 
valves and levers, the law of gravitation and effects \ 
of specific gravity in mixtures of weight or fluids, i 
mental and physical qualities are also necessary. 
He must have a well balanced mind, able to keep 
cool under all circumstances, good sight, hearing. 



January 15, 1921.] 



BOOK REVIEWS. 



123 



touch and smell. They have to tell him nmch dur- 
ing an operation. The lure is in the variety of the 
work. The prohlems are endless, arising from the 
state of the patient, the nature of the operation and 
the patient's idiosyncrasy — an unknown quantity. 
Though the responsibilities are great, the operation 
once over, the anesthetist's task is, as a rule, fin- 
ished. There is a certain sporting element, though 
the more one plays the game, the more the rules 
and probabilities are grasped and perfection reached. 
Anesthetists vary, but Barton names five years as 
a period for mastering the essentials, and another 
five to deal with every emergency. 

Some points on chloroform are then dealt with, 
also alkaloids, their use and abuse, gas, modern 
methods, finally, shoals and rapids. Barton com- 
pares American and English methods, but is cer- 
tainly justified in quoting his own methods based 
on success in thousands of cases. His rare fail- 
ures, frankly given, his genial way of giving infor- 
mation, all tempt the reader to do more than glance 
over this helpful volume. 

MOON-CALF. 

Moon-Calf. Bv Flovd Dell. New York : Alfred A. 
Knopf, 1920. ' 

Moon-Calf is a book so unusual in the annals of 
our literature that it should be read at once by 
everyone interested in American life and in litera- 
ture as a fine art. It is the biography of a young 
near rebel of the middle west, who develops in the 
extraordinarily inarticulate environment of a small 
lUinois town, but it is more. Floyd Dell shows 
here the grim and arid subsistence which the small 
town has to ofifer to the young man of talent — • 
which America herself has to offer to the young man 
of talent, though the author may not have meant 
anything so sweeping. With all this, Moon-Calf 
is a novel which, once started, it is impossible to 
put down, written in the "light and laughing" 
prose to which the author refers, and with a delicate 
and distinguished craftsmanship. 
1 Of particular interest to physicians is the fact that 
: this book is, in a sense, a product of psychoanalysis. 
[ Many writers enunciate truths about the hidden 
I places in the human soul of whose implications they 
)• are only half aware — a manner of revelation. Mr. 
Dell is entirely articulate on that score. He does 
not talk about complexes, but he interprets the events 
of his hero's life from childhood on with a deft and 
sure analysis that is truly illuminating. One might 
almost say that this book could not have been written 
' if Mr. Dell had not been aware of how Felix Fay's 
fear of living influenced his every action. And he 
shows the origin of this fear in the childhood of 
Felix, a dreamy, bookish, fragile child among a 
^roup of hoydenish brothers and sisters and school- 
mates, a child who compensated for his manifest 
physical inferiority and his helplessness by a con- 
tinuous life of fantasy. Felix's great effort, like 
that of all such young persons, is to translate him- 
self into a living human being. 

It is not entirely Felix's fault, of course, that he 
grew up on dreams instead of realities. Partly his 
flight was due to the fact that he was so fearfully 
isolated. There weren't any others like him. There 



was no appreciable intellectual life in Maple and 
Vickley, nothing to feed his imagination but the 
incredibly bare existence of a poor middleclass 
family in a small middle western town. If he took 
to books and dreams, it was because there was 
nothing else to take to. The one exception of his 
younger days is the episode of Rose Henderson, 
with its brief and poignant loveliness. 

One cannot say that Felix was the victim of 
Puritanism as much as of sheer emptiness. His 
home was the library, where he read a jumble of 
everything under the sun, but it was a scattered,. 
ungu"ded reading. School brought him nothing in 
the way of intellectual stimulus. And this solitary, 
secluded, ingrowing life of his in books made him 
a personality lacking in color and positiveness. 
This is aptly shown in the remark of the novelist, 
Tom Alden, after Felix has been taken to meet him : 

" T ought to like him. But how can you like a 
person who isn't there? I like everything he says. 
But there doesn't seem to be anybody saying it. 
Darn it all, Helen, he isn't real !' " 

But Felix does come to himself, and this through 
a somewhat devious means, beginning with his intro- 
duction to Socialism. Socialism is for him some- 
thing more realistic than anything he has ever en- 
countered, and in the Central Branch he finds peo- 
ple, too, who bring him realism. There is a salutary 
cruelty in the verdict of Comrade Vogelsang on 
Felix's poetry, the pretty poems that have always 
met with such deferential praise. 

" 'You have been mooning about, writing verses 
about life, instead of living,' " says this healthy 
philosopher. "'You have been afraid to live. Most 
people are. Something stands between them and 
life. Not only economic conditions : something else 
— a shadow, a fear. Perhaps it is safer not to try, 
they think. So do you. These poems are your con- 
solations for not living. . . . You have a future 
— a great future — as a consoler of weak souls.' " 

Socialism plays an important part in Felix's life, 
partly because he is helpless economically, drifting 
from one factory to anotlier and hating his jobs with 
a feeble and futile hatred. But it is a newspaper 
work which sets him on his feet — newspaper work 
with its enforced contact with people and ideas, its 
joy of creation, its adventurousness. Felix is a 
better writer of human interest stories and dramatic 
critic than a news reporter, but it is in the back 
room of the undertaker's establishment while hunt- 
ing for news and talking to the rival reporter from 
•the other paper that he begins to learn how to meet 
the world he lives in. 

There are women in this story, of course — quite a 
number of them, beginning with the half dreamlike 
playtime with Rose Henderson when Felix is a child 
and ending with the inherently conventional Joyce 
Tennant. There is also Margaret, who was to him 
unreasoning romance, and there is Daisy, whose 
offering, though sincere, is somewhat too sordid. 
But Felix does not marry in this book, though it is 
not exactly his fault. At the end Joyce turns him 
down for a protective male, which P'elix decidedly 
is not, and Felix is left with his face set toward 
Chicago — the next step. 

It is a dififerent Felix, though, from the early 



124 



BOOK REVJEIVS. 



[New York 
Medical Journal. 



helpless youth — a Felix who has learned the joy of 
artistic creation and of love, who has found his 
work — for the time being — and who has learned 
that a hostile world cannot batter down his indi- 
viduality. He has learned, moreover, that there are 
others like himself. This is perhaps the most im- 
portant lesson of all. He has become a personality. 

All this is, of course, much more a personal 
record than a criticism of American culture, though 
it is that as well. But it is primarily that absorbing 
story which every writer longs to put on j)aper and 
usually does — the story of finding himself. It is 
because FeHx reaches out in many directions that 
Moon-Calf has so large a scope. The book should 
be widely read. With its selfknowledge, -t.- sure 
yet delicate incisions into the fabric of our social 
and economic life, its fluid and lovely lechnic. it is 
a significant first novel and certainly a most .lote- 
worthy book. 

YESTERDAY AND TODAY. 

Caius Graccluis. A Tragedy. By Odix Gregory. With an 
Introduction by Theodore Dreiser. New York : Boni & 
Liveright, 1920. Pp. 172. 

Dreiser's introduction has performed the re- 
viewer's task so well that little remains to be said. 
That little, however, afifords opportunity to empha- 
size the values that this virile work brings so unex- 
pectedly to our present day reading world. It is 
an unexpected thing to come. upon this drama of 
measured beauty, strength, and quiet but absolutely 
fearless setting forth of truth. Dreiser has boldly 
placed the writer high in the realm of letters both 
for his thought and form. 

One wonders at first if the place has been meas- 
ured too high. Here is a drama of an almost for- 
gotten history. Any message for today may be 
lost in the dullness with which time tarnishes the 
most brilliant of events. Then as one reads and 
finds that these old pages have been so clearly 
evoked that each character does live and breathe, 
another objection arises. There is startling simi- 
larity to the evils of today which go about in the 
same sheep's clothing. There is sharp conflict be- 
tween protection at any price, utilized for any selfish 
end, and, opposed to it, the sincerity of real con- 
structive expansion with opportunity for each and 
all. It seems as if the dramatist must simply have 
wrenched present economic conditions out of their 
setting and readapted a historical garb to them. 
Gregory himself has anticipated such a charge by 
giving us in footnotes as well as in his preface the 
simple facts and the unadorned statement of them 
by the historians of that far distant Rome. 

The reader can only feel, therefore, with Dreiser, 
that Gregory has something to say, something that 
is eternally human, that recalls men today as it 
would have done in that past age, to judge clearly 
between two aims, incompatible, irreconcilable. One 
is genuinely constructive, self forgetful in engaging 
the self in something larger than the narrow ends 
of its own gratification. On the other hand, is the 
self steeped in greed of power, wealth, pleasure, 
and stupidly or maliciously fearful of progress 
which threatens such arrogated possessions? So 
well does the drama represent these contrasted aims, 
each in its own way, that the hero is broadly human 



in his heroism, awakening responsive chords of our 
best aspirations, evoking righteous indignation in 
his defeat; and the drama must be read closely to 
detect the machinations devoted to his defeat. For 
here is the same plausibleness with which selfishness 
today deceives the very elect, those who would fain 
follow what is worthy. Surrounding these in the 
play are to be seen also those of the herd who 
hearken to the last voice which has spoken, the 
unthinking men who are swayed indifferently to one 
side or the other. 

It is true that the character drawing is distinctly 
individual. The long speeches, as Dreiser has said, 
we do not avoid. One returns rather fascinated to 
reread the truth they express, to discern the charac- 
ter lineaments they contain. Lydia's long harangue 
in Act IV gives a vivid picture both of the woman 
and the man who prostitute one another and society 
to their own gain or pleasure. The setting of the 
speech saves it from being a merely moralistic dis- 
play of the dramatist and makes it only more 
poignantly relevant to the drama's purpose. It can 
be agreed that the drama is indeed vital enough to 
be brought to the stage. 

CLEMENCEAU'S SHORT STORIES 

Tl'.c Surprises of Life. By Georges Clemenceau. Trans- 
lated by Grace Hall. Garden Citj' and New York: 
Doubleday. Page & Co., 1920. Pp. vi-326. 

The name of this book is the only thing that 
invites adverse criticism. It is inadequate ; it be- 
longs to the conventionality which the author so 
gracefully flays throughout these stories. Perhaps 
in its original form the name conveys more of the 
exquisitely subtle flavor of the book. The writer 
discloses facts in character and behavior which only 
a keen observation would discover. The existence 
of these realities in his sometime neighbors, even 
feathered ones, might come as a jolting surprise to 
many readers were they less cleverly brought to 
view. But so skillfully does Clemenceau turn these 
natures over to discover their reverse sides that his 
revelations strike gently. So keen is his probing, 
so accurate his anal}-sis of what lies there, that his 
revelations cannot be taken lightly. They arouse 
serious reflection upon human nature. 

The reader is awakened "to share tlie writer's rare 
sympathy, his patient understanding of the slow- 
ness, the unevenness of human development. He 
comes not to censure the fumbling stupidity of lives 
bound under custom, unaware of their own possi- 
bilities. There is a genuine pity, rather, not un- 
tempered with the brightness of hinnor. With this 
the reader follows the peasant, the monotonous 
toiler, the cunning selfseeker even, and those also 
who, bound in by conventional demands, find private 
tragic exercise for the irrepressible flames of hatred, 
the distortion of what might have been love. It is 
a pity which is rather a sympathetic attempt better 
to understand human society and the limitations 
and conflicts which continue in it. as the soil out 
of which, slowly, something else may arise. 

The shafts of censure direct themselves in a 
satire no less true because gracefully tipped. These 
arc aimed against cupidity, the brilliant traditions 
which blazon upon such foundation, the approval of 
men and women for only these protecting appears 



January 15, 1921.] 



BOOK REVIEWS. 



125 



ances. Otherwise the wisdom of this keen analyst 
is proffered in the brighter and sadder notes of the 
countryside, the picture that wins the heart to inner 
reaHties. These find their own, sometimes, in spiti 
of the outward smothering conceits. They flourish 
even when in the end they must pay penalty to the 
latter. 

No one can read the book thoughtfully without 
a closer realization of these inner truths of human 
lives, and without a thrust of responsibility toward 
that which is within and away from the falseness 
without. In this insistence on the individual and 
his sincerity to himself one catches a glimpse of 
the source of Clemenceau's own unique power, that 
of the strong man of France. 

I AN ADVENTUROUS DOCTOR. 

' The Story of Doctor Dolittlc. Being the History of His 
Peculiar Life at Home and Astonishing Adventures in 
Foreign Parts. Never Before Printed. Told by Hugh 
Lofting. Illustrated by the Author. New York : Fred- 
erick A. Stokes Company, 1920. Pp. 180. 

I Put yourself in his place, leave aside the incredu- 
lity, the superciliousness of unmellowed age. Curl 
up in an armchair with Doctor Dolittle's book, recall 
the pleased expectancy with which you once received 
a new book, and, in a short while, you will find 
your big toe waggling and a red flush of gratified 
desire aflame on your cheek, and a smile of full 
content, like Prince Bumpo on page 96. 

John Dolittle, M. D., loved animals, and eventu- 
ally, growing poorer, became a doctor for animals, 
and his clever parrot taught him animal language, 
but he did not make much money. Suddenly, he 
had a wire from Africa, saying a dreadful sickness 
had attacked the monkeys. Would he come and 
help them? Well, he had no money, but a sailor 
lent him a boat, and then the fun begins. He fairly 
tumbles into adventures, wild beasts, pirates, a mix- 
ture of all that children love, with a wild disregard 
of probabilities or commonplace sequences. The 
author evidently knows children well. He does not 
talk down to them or slyly insert sentiment to please 
the grownups, so that they may say, "What a sweet 
story! I must get it for Tommy." No. he does 
not care for grownups one bit ; just loves the 
children. 

^ 

New Publications Received. 



[We publish full lists of books received, but we acknowl- 
edge no obligation to review them all. Nevertheless, so 
far as space permits, we review those in which we think 
our readers are likely to be interested.] 



MASTER EUSTACE. By Henry James. New York : 
Thomas Seltzer, 1920. Pp. 280. 

COLLECTED POEMS. By ALFRED NoYES. Voume HL New 
York: Frederick A. Stokes Company, 1920. Pp. ix-315. 

aviation medicine in the .a. e. f. Prepared in the Office 
of the Director of Air Service. Washington : Government 
Printing Office, 1920. Pp. 322. 

the rockefeller foundation international health 
BOARD. Sixth Annual Report. January 1, 1919-December 
31, 1919. New York : 61 Broadway, 1920. Pp. xiii-210. 

the seven wives of BLUEBEARD AND OTHER MARVELOUS 

TALES. By Anat(5le France. a Translation by D. B. 
Stewart. London and New York : John Lane Company, 
1920. Pp. vi-216. 



POOR WHITE. By Sherwood Anderson. New York: B. 
W. Huebsch, Inc., 1920. Pp. 371. 

MARIE Claire's workshop. By Marguerite Audoux. 
Translated by F. S. Flint. New York : Thomas Seltzer, 
1920. Pp. 239. 

the golden barque and the weaver's grave. By 
Seumas O'Kelly. New York and London: G. Putnam's 
Sons, 1920. Pp. 253. 

the revels of orsera. .a. Mediaeval Romance. By Ron- 
ald Ross. New York: E. P. Dutton & Co., 1920. Pp. 
vi-393. 

instinct and the -unconscious, a Contribution to a 
Biological Theory of the Psychoneuroses. By W. H. R. 
Rivers, M.D., D.Sc, LL.D., F.R.S., Fellow and Praelector 
in Natural Sciences, St. John's College, Cambridge. Cam- 
bridge: The University Press, 1920. Pp. viii-252. 

the essentials of histology. Descriptive and Practical 
For the Use of Students. By Sir Edward Siiarpey 
Schafer, F. R. S., Professor of Physiology in the Uni- 
versity of Edinburgh ; Formerly Jodrell Professor of Physi- 
ology in University College, London. Eleventh Edition. 
Philadelphia and New York: Lea & Febiger, 1920. Pp. 
xi-577. 

syphilis. By Loyd Thompson, Ph. B., M. D., Physician 
to the Syphilis Clinic, Government Free Bath House ; Visit- 
ing Urologist to St. Joseph's Hospital ; Consulting Patholo- 
gist to the Leo N. Levy Memorial Hospital, Hot Springs, 
Arkansas, etc. Illustrated with Eighty-one Engravings and 
Seven Plates. Second Edition, Thoroughly Revised. 
Philadelphia and New York : Lea & Febiger, 1920. Pp. 
xix-486. 

CLINICAL OPHTHALMOLOGY FOR THE GENERAL PRACTITIONER. 

By A. Maitland Ramsay, M.D., Fellow of Royal Faculty 
of Physicians and Surgeons, Glasgow ; Lecturer on Oph- 
thalmology, University of Glasgow ; Ophthalmic Surgeon, 
Glasgow Royal Infirmary, etc. With Foreword by Sir 
James Mackenzie, M.D., F.R.S. London : Henry Frowde 
(Oxford University Press) and Hodder and Stoughton. 
1920. Pp. xx-500. 

A TEXTBOOK OF PHARMACOLOGY AND MEDICAL TREATMENT 

FOR NURSES. By J. M. Fortescue-Brickdale, M.A., M.D. 
(Oxon.) M.R.C.P. (Lond.) Capt. R.A.M.C. (T.F;.) ; 
Physician to the British Royal Infirmary and Clinical 
Lecturer in the University of Bristol ; formerly Lecturer 
on Pharmacology in the University of Oxford. London : 
Henry Frowde (Oxford University Press) and Hodder 
and Stoughton, 1920. Pp. xiii-392. 

principles of biochemistry. For Students of Medicine, 
Agriculture and Related Sciences. By T. Brailsford Rob- 
ertson, Ph. D., D. Sc., Professor of Physiology and Bio- 
chemistry in the University of Adelaide, South Australia; 
Formerly Professor of Biochemistry in the University of 
Toronto ; Professor of Biochemistry and Pharmacology in 
the University of California. Illustrated with Forty-nine 
Engravings. Philadelphia and New York: Lea & Febiger, 
1920. Pp. xii-633. 

tropical OPHTHALMOLOGY. By RoBERT HeNRY ElLIOT, 

M.D., B.S. (Lond.), Sc.D. (Edin.), F.R.C.S. (Eng.), 
Lieutenant-Colonel I.M.S. (Retired), Late Superintendent 
of the Government Ophthalmic Hospital, Madras and 
Professor of Ophthalmology, Medical College, Madras, 
Honorary Fellow and Gold Medallist of the American 
Academy of Ophthalmology and Otolaryngology, etc. With 
7 Plates and 117 Illustrations. London: Henry Frowde 
(Oxford University Press) and Hodder and Stoughton, 
1920. Pp. xxiii-525. 

HISTORY AND BIBLIOGRAPHY OF ANATOMIC ILLUSTRATION IN 
ITS RELATION TO ANATOMIC SCIENCE AND THE GRAPHIC ARTS. 

By LuDWiG Choulant. Translated and Edited with Notes 
and a Biography by Mortimer Frank, B. S., M.D., Secre- 
tary, The Society of Medical History, Chicago; Attending 
Ophthalmologist, Michael Reese Hospital, Chicago. With 
a Biographical Sketch of the Translator and Two Additional 
Sections by Fielding H. Garrison, M.D., and Edward C. 
Streeter, M. D. Chicago : The University of Chicago 
Press, 1920. Pp. xxvii-435. 



Practical Therapeutics and Preventive Medicine 

A Compendium of Treatment and Prophylaxis, Original and Adapted 



Treatment of Neurosyphilis by the Intraspinal 
Route. — Albert Keidel and Joseph Warle Moore 
(Bulletin of the Johns Hopkins Hospital, Novem- 
ber, 1920) gave twenty-five cases of neurosyphilis 
intraspinal injections of mercurialized serum, fol- 
lowed within twenty-four hours by an intravenous 
injection of arsphenamine. This method of treat- 
ment was designed to test a conclusion of Swift that 
local irritation may increase the permeability of the 
meninges. Mercurialized serum was chosen be- 
cause of its irritating ef¥ect, and intraspinal treat- 
ments were given in courses, usually of six treat- 
ments, administered one each week, and each course 
was followed by ten to twelve weeks of mercury 
inunction. The clinical resiilts of this treatment 
were good in about sixty per cent, of the cases, but 
the serological results were poor in practically all 
the groups treated. A comparison of the data with 
those of other workers shows that the results ob- 
tained from mercurialized serum, used by the 
method the authors describe, are inferior to results 
obtained either by themselves or by others with 
the Swift-Ellis method. The conclusions drawn are 
that intraspinal therapy is a necessary and rational 
adjunct in the treatment of neurosyphilis in cases 
which fail to respond to routine antisyphilitic treat- 
ment. The mode of action of intraspinal medica- 
tion does not depend upon increased permeability 
of the meninges. Aseptic meningitis produced by 
intraspinal injection of irritants may prove an un- 
toward rather than a beneficial factor in the treat- 
ment of neurosyphilis. 

Different Types of Streptococci in War 
Wounds. — Pierre Pruvost (Paris medical, Feb- 
ruary 21, 1920) points out that in the bacterial 
flora of war wounds two sorts of streptococci may 
be dififerentiated. The first is pathogenic and causes 
a severe, febrile constitutional reaction ; the other 
causes no marked general symptoms. The first 
type consists nearly always of hemolytic strepto- 
cocci, and forms homogeneous chains composed of 
regularly arranged cocci or cocci undergoing repro- 
duction by fission. The second type usually con- 
sists of nonhemolytic streptococci, and the chains 
formed are not homogeneous, being composed of 
unlike, unequal, and irregular cocci. The cultures 
of the second type are generally more robust than 
those of the first. Where a distinction between the 
two types within twenty-four or forty-eight hours 
is imperative, precluding isolation and secondary 
identification, one should endeavor to establish the 
distinction on the basis of the foregoing morpho- 
logical characteristics. In doing so the length of 
the chains of bacteria, the rounded or oval outlines 
of the cocci, as well as their size, should be dis- 
regarded, attention being directed exclusively to the 
regularity or irregularity of the several cocci com- 
posing the individual chains. Great length and 
curling of the chains are not characteristic of the 
streptococci. Even at the first inoculation in bouil- 
lon enterococci similarly disposed were noted. 



A Pharmacological Study of Benzyl Benzoate. 

• — Edward C. Mason and Carl E. Pieck (Journal of 
Laboratory and Clinical Medicine, November, 1920) 
say that, owing to the fact that a considerable 
number of clinical conditions, such as are due to 
increased activity or increased tonus of the in- 
testinal tract, excessive or abnormal contraction of 
the uterus, bronchial spasm, etc., have been described 
as being benefited by the use of the benzyl esters. 
They have attempted to study the mechanism by 
which these conditions are relieved, and to ascer- 
tain the concentration of the drug in the blood 
necessary to produce the desired results. Their 
experiments with dogs are fully reported, and the 
results given in detail. 

Genital Tuberculosis in the Male. — J. Dellinger 

Barney (American Journal of Surgery, August, 
1920) presents among his conclusions the following 
which he considers of importance: 1. The epididy- 
mis is the primary focus in the genital tract. 
2. It is always secondary to a focus elsewhere 
in the body, this focus being situated most often in 
the lung. 3. The prostate and seminal vesicles are 
invaded by the disease early and often, but after re- 
moval of the epididymis clinical cure is finally estab- 
lished. 4. The second epididymis becomes involved 
in at least half the cases, but involvement of this 
organ may be obviated by early resection of its vas 
deferens. 5. Orchidectomy is unnecessary if the 
testicle is free from disease, and even if affected 
the diseased portion can be successfully removed in 
many instances. Even a portion of one or both 
testicles is worth saving, both on account of the 
internal secretion and the mental effect upon the 
patient. After castration the sexual function may 
be unimpaired. 

Value of the Wassermann Reaction in Obstet- 
rics. — J. Whitridge Williams (Bulletin of the 
Johns Hopkins Hospital, October, 1920) found that 
449 women, delivered between April, 1916, and 
December 31, 1919, gave a positive Wassermann 
test, the incidence being much greater in the black 
than the white woman, 16.29 and 2.48 per cent, 
respectively. The figures showed that less than 
one half of such women will have syphilitic chil- 
dren. The cases were divided into three groups, 
those that had been well treated, those which were 
imperfectly treated, and those which were not 
treated at all, the incidence of syphilitic children 
being for these groups 6.7, 33.2, and 48.5 per cent., 
respectively. However, of sixty-five women giving 
a negative Wassermann test, forty-three of their 
children were definitely syphilitic, eleven others died 
but were not autopsied, three were negative at 
autopsy, and eight were discharged in good con- 
dition. The information obtained from the Was- 
sermann tests made on the fetal blood is not con- 
sidered to be commensurate with the time consumed 
nor the money spent on such investigations. It is 
also considered hazardous to draw any conclusions 



January 15, 1921.] PRACTICAL THERAPEUTICS A.XD I'REl-EXTIVE MEDICINE. 



127 



concerning the condition of the placenta or of the 
child from the existence of a positive maternal 
Wassermann during pregnancy. The microscopical 
examination of the placenta tallied with the cHnical 
and anatomical findings in the child in from eighty 
to ninety per cent, of the cases, which is a marked 
contrast to the forty per cent, obtained from a 
positive maternal Wassermann. Williams discusses 
Colles's law, and states that in his opinion the pos- 
sibility of spermatic infection and the admissibility 
of Colles's law have not yet been conclusively 
proved or disproved. 

Virulent Diphtheria Bacilli Carried by Cats. — 
James S. Simmons {American Journal of the Medi- 
cal Sciences, October, 1920) reports a case in which 
an elderly woman developed a fatal diphtheritic 
pharyngitis after close contact with a cat which had 
been sick one week. A second cat which had been 
in contact with the first cat became sick and died 
ten days later. The patient had a grayish brown 
pseudomembrane covering her uvula, tonsils, and 
posterior pharynx. The first cat had a small yel- 
lowish gray pseudomembranous ulceration in the 
left nasal passage, the second cat showed ulcera- 
tions of both vocal cords covered with a grayish- 
white false membrane. Diphtheria bacilli of inter- 
mediate virulence for guineapigs were isolated from 
all three lesions. 

Treatment of Diphtheria Carriers. — A. R. Era- 
ser and A. G. B. Duncan {Lancet, November 13, 
1920) differentiate between a "positive throat" and 
a "true diphtheria carrier." The latter carries bac- 
teria which retain their virulence despite the most 
energetic disinfection. Stock diphtheria vaccine 
cures the positive throat, but up to the present time 
no thorough cure has been offered for the true 
carrier. The authors base their work on the theory 
that in a carrier there is equilibrium between the 
power of immunity of the individual and the toxin. 
A detoxicated Klebs-Loffler vaccine, prepared after 
the manner of E). Thompson, was used in three 
cases outlined in the paper. All lethal bacteria dis- 
appeared after inoculations of constantly increasing 
concentrations. It is pointed out that the treatment 
may be used on convalescents in case of delayed 
resolution, and the method apparently offers im- 
munity to those exposed to infection. 

Diphtheria Bacillus Carriers. — C. G. Guthrie, 
J. Gelien, and W. L. Moss {Bulletin of the Johns 
Hopkins Hospital, November, 1920) report the re- 
sults of an extensive investigation, covering the 
examination of eight hundred school children. 
From this study they conclude that the diphtheria 
bacilli present in a majority of healthy carriers are 
avirulent, that such bacilli cannot produce diph- 
theria, and that there is no proof that they can 
acquire virulence. It is, therefore, evident that 
carriers of avirulent diphtheria bacilli are not a 
menace to anyone in particular or the community 
as a whole, and interference with their liberty on 
the grounds of their being carriers is not warranted 
and is unjustifiable. The standard guineapig test 
is beheved to be a safe one for virulence, but there 
is an urgent need for a simpler, quicker, and less 
expensive virulence test to be developed. The 
carrier of the virulent diphtheria bacillus is of course 



another matter, and while it is believed that the 
danger from such carriers has perhaps been over- 
estimated, the authors recognize the fact that diph- 
theria bacilli derived from such a source may give 
rise to the disease in susceptible persons. 

The Effect of Diphtheria Antitoxin in Pre- 
venting Lodgment and Growth of the Diphtheria 
Bacillus in the Nasal Passages of Animals. — J. 

Gelien, W. L. Moss, and C. G. Guthrie {Bulletin 
of the Johns Hopkins Hospital, November, 1920). 
The object of this investigation was to determine 
whether antitoxin adrriinistered subcutaneously 
would prevent the subsequent lodgment and growth 
of diphtheria bacilli in the nasopharynx. Guinea- 
pigs, rabbits and cats were used. The production 
of nasal infection or infestation with Bacillus diph- 
therise was quite inconstant, even when the organisms 
were introduced directly into the nose, and the dura- 
tion of infection was usually quite brief. The health 
of the animals was apparently not affected by the 
mere presence of the bacilli in the nose. The occur- 
rence and duration of infection were independent 
of the virulence of the strain of organism inocu- 
lated, and were wholly unaffected by the previous 
administration of antitoxin. 

Treatment of Single Ostosis of Long Bones. — 

Reel and Hugger {Military Surgeons. September, 
1920) state that the individual case determines the 
treatment. Should the exostosis be superficial and 
subject to repeated irritation or injury the possi- 
bility of sarcomatous change resulting therefrom 
must be recognized, and the outgrowth removed. 
Removal is also indicated when the tumor mass is 
found in such a position as to produce a mechanical 
derangement in the normal function of a joint, 
muscle or tendon. The same applies when the 
exostosis is encountered along the course of impor- 
tant nerves or blood vessels and producing nervous 
or circulatory complications. When the bony tumor 
is innocentlv situated, it can be left unmolested. 

Treatment of Goitre with Radium. — -A. N. 

Clagett {Illinois Medical Journal, October, 1920) 
believes that radium should be given a trial in 
exophthalmic goitre, because there is no mortality, 
no scar, no pain, and only three or four days' 
hospitalization. Its advantages over the x ray are 
that it produces no discoloration of the neck, there 
is less time consumed in the treatment, and it is 
simpler to apply. The selective action of radium 
destroys the harmful cells, while not disturbing the 
healthy cells. Surgery has not been necessary in 
any one of forty-seven cases extending hack over 
three years. 

Etiology and Treatment of Gastric Ulcer. — 

fohn F. Van Paing ( Auicrica)i Medicine. Novem- 
ber, 1920) firmly believes that infection is the sole 
cause of gastric ulcer ; that gastric drainage is a 
myth, and that gastroenterostomy is to be done 
only to relieve obstruction to the passage of food 
or to diminish the irritation of a pyloric ulcer. 
Ulcer in the corpus is to be treated by excision with 
the cautery and closure without gastroenterostomy. 
Small stomata prevent the vomiting, pain and diar- 
rhea so common in large openings made for "gastric 
drainage and rest." 



128 



PRACTICAL THERAPEUTICS AND PREVENTIVE MEDICINE. 



[New York 
Medical Journal. 



Value and Significance of Blood Pressure in 
Obstetrics. — Albert G. Schuize {Minnesota Medi- 
cine, December, 1920) considers that a series of 
blood pressure readings properly taken, rather than 
a series of urine analyses, serve as an index of the 
eclamptic or noneclamptic condition of the patient. 
The normal range of blood pressure during preg- 
nancy is between 100 and 130 systolic; if it be 
below 100 be prepared for shock, if over 150 it is 
no longer normal. , 

Treatment of Eclampsia. — James A. Martin 
(Charlotte Medical Journal, August, 1920) guards 
against eclampsia by examining the urine every two 
weeks. Do not lay too much stress on negative 
findings. The blood pressure should be taken 
regularly as it is of great importance. He does not 
consider the use of veratrum viride advisable. In 
every case of actual eclampsia the uterus' should I)e 
emptied as quickly as possible, preferably by 
Cesarean section. 

Surgical Treatment of Cerebral Hemorrhage in 
the Newborn. — A. C. Strachauer (Minnesota 
Medicine, December, 1920) writes that untreated 
cerebral hemorrhage is responsible for fifty per cent, 
of stillbirths and deaths of infants within the first 
week of life. The coagulation and bleeding time 
estimation should become a routine procedure in the 
newborn, followed by the injection and transfusion 
of blood when indicated. Infratentorial hemor- 
rhage of infancy may be treated by lumbar punc- 
ture ; supratentorial hemorrhage requires prompt 
l^erformance of a craniotomy. 

The Treatment of Syphilis of the Central 
Nervous System. — Clyde L. Cummer (Ohio State 
Medical Journal, September, 1920) summarizes the 
treatment as follows : It must be intensive and pro- 
tracted; in some manifestations it may be utterly 
powerless. Syphilitics should be treated vigor- 
ously and should be kept under observation until 
clinical and laboratory examinations prove that the 
infection has been eradicated in the nervous system 
as well as elsewhere. 

Rest and Exercise in the Treatment of Heart 
Disease. — Joseph H. Pratt (Southern Medical 
Journal, July, 1920) says that rest was formerly 
thought to weaken the heart, but is now known to 
act beneficially by increasing the reserve force of 
the enfeebled heart. The reserve force measured by 
the vital capacity can be greatly increased by rest 
alone. Proof is lacking that exercise strengthens 
the degenerated heart. Absolute rest is of great 
value in the treatment of angina pectoris. 

Pneumonia in a Woman with a Habitual High 
Blood Pressure. — J. Konikow (Boston Medical 
and Surgical Journal, July 1, 1920) reports a case 
of this nature in a woman of fifty-four whose blood 
pressure for the preceding two years had been 
between 225 and 275, despite repeated attempts to 
reduce it. Pneumonia reduced it to 130 within 
three days. Its rise was welcomed as the surest 
sign of approaching recovery and when it had 
reached its habitual height the patient had recovered. 
The moral drawn is to leave high blood pressure 
alone, if its cause cannot be removed. In itself it 
is Nature's means of selfdefense. 



Sugar in the Blood.— R. L. M. Wallis and C. D. 
Gallagher (Lancet, October 16, 1920) have devised 
a convenient and accurate means of estimating 
sugar in blood. Only a few drops of blood are 
required. The blood is absorbed on a weighed 
blotting paper, the sugar extracted, and estimated 
by comparatively simple operations. There is no 
inconvenience to the patient, and the analysis is of 
great utility in diagnosis and treatment. 

Effects of Feeding with Calcium Salts on the 
Calcium Content of the Blood.— W. Denis and 
A. S. Minot (Journal of Biological Chemistry, 
March, 1920) foimd that it was impossible to in- 
crease the calcium content of the blood of six 
normal human subjects by the daily ingestion of 
calcium lactate for a period of six to ten days. 
Experiments were then carried out on rabbits and 
cats, and it was sometimes possible to increase the 
calcium content of their blood by feeding with cal- 
cium salts, if the original calcium content of the 
blood was rather low. 

Pregnancy in a Rudimentary Horn of the 
Uterus. — O. Paul Hempstone (Surgery, Gyne- 
cology and Obstetrics, November, 1920) states that 
with more careful history and examination, the 
diagnosis of this condition can usually be made. In 
all cases of rudimentary cornua of the uterus the 
pedicle should be examined by serial sections to 
confirm the presence of a microscopical canal 
through which impregnation occurs. All rudimen- 
tary cornua should be removed so soon as the diag- 
nosis is made. 

Function of Corpus Luteum. — Edward H. 

Ochsner (Surgery, Gynecology and Obstetrics, 
November, 1920), in a series of observation on the 
use of corpus luteum, concludes as follows: 1. 
That an unabsorbed false corpus luteum prevents 
ovulation and is a common cause of sterility and 
that the expression or excision of such a false corpus 
luteum invariably brings on menstruation. 2. That 
the excision or rupture of a true corpus luteum 
invariably results in interruption of pregnancy, at 
least during the early months of preganacy, and 
that it may be looked upon as a common cause of 
abortion. 3. That an injury to either the true or 
false corpus luteum may simulate ruptured extra- 
uterine pregnancy. 

Effects of the Various Toxemias upon the Eye. 

— W. H. Wilmer (Archives of Ophtlialmology, 
September, 1920) says that whatever may be the eti- 
ology of the ocular expression of the toxemia, the 
first thing to be done is to eradicate all toxic sources, 
and then to simulate nature's measures by bringing 
increased numbers of leucocytes to the zone of ac- 
tivity. This may be accomplished by the local use 
of hot applications, and, as certain stages of the in- 
flammation, dionin and subconjunctival injections. 
Nearly all involvements of the anterior portion of 
the uveal tract require tropine. Deficiency in the 
secretion of glands should be supplied by organ 
therapy. In case of retinal hemorrhages accom- 
panied by a prolonged coagulation time, the use of 
lime salts is indicated. In all toxemias the gastro- 
intestinal tract must receive attention both in regard 
to diet and therapeutics. 



Miscellany from Home and Foreign Journals 



Developmental Forms of the Spirillum of Re- 
lapsing Fever. — Ardin-Delteil and Derrieu (5m/- 
letin dc I'Academie de medecine, March 23, 1920) 
found various hitherto undescribed forms of the 
spiriHum of relapsing- fever in the cerebrospinal 
fluid, blood and pleural and joint effusions in cases 
of this disease. In the blood stream there were 
found, apart from the well known spirilla, small 
granular bodies and short or elongated rods, all 
highly motile, and persisting in the blood in the 
interval of apyrexia and even for a time after the 
final defervescence. These bodies were also seen, 
though inconstantly, in the cerebrospinal fluid and 
pleural and joint fluids. There were also found in 
the same fluids structures analogous to the Balfour 
or Leishniann bodies. When fixed and stained, 
these structures appeared as rounded, oval, or ir- 
regularly shaped bodies, ^shaped somewhat like red 
corpuscles, and measuring two to five microns in 
diameter. At the periphery of each were seen a 
large number of minute granules and, when derived 
from the cerebrospinal fluid, also long, fusiform 
bodies nine or ten microns in length, sometimes 
curved, and with an elongated nucleus. Further, 
the source of all these bodies was found in the 
cerebrospinal fluid of two patients in the form of 
large bipartite cells thirty to forty microns in 
diameter and presenting the appearance of proto- 
zoa. Each of these cells contained two nuclei, and 
at its surface showed numerous pedunculated pro- 
cesses, some eventually breaking oi¥ and giving rise 
to the granular and fusiform bodies already men- 
tioned. In the younger protozoan forms the pro- 
cesses were represented merely by slight surface 
elevations. Apparently the usual method of repro- 
duction of the protozoon is by ordinary kinesis. 
Under certain circumstances, however, possibly 
when the parasite is in a weakened condition, the 
cell goes through a process of parthenogenesis 
whereby granular and fusiform bodies are set free 
from its periphery. Godlewski's experiments have 
shown that even such small, fragile, unnucleated 
fragments may later reproduce the active virus. 

Social Service and the Clinic. — Alfred C. Reed 
{Boston Medical and Stirgical Journal, May 6, 
1920) refers the criticisms of the free public clinic 
to one of three heads: 1. Abuse of the clinic by 
patients able to pay. To whatever degree this is 
true, the criticism is justified. He is of the opinion 
that the bulk of those who appear to be able to pay 
should be classed among the borderline cases, which 
require judgment and social study, and that the 
prevention of this abuse rests with the social service 
department. 2. Clinics act as feeders for the pri- 
vate practice of the attending staff. In so far as 
patients are found by the social service department 
to be able to pay, it is right that they should be 
referred to members of. the staff in rotation as 
private patients. 3. Poor service to the patient, 
wholesale medical practice, aiming at number and 
quantity, rather than careful, efficient, scientific 
work. Full and careful clinical records, preserved 
in a permanent file, will go far toward improving 



the character of clinic service. Not a large clinic, 
but one characterized by careful and accurate 
diagnosis and treatment, should be the objective. 
The functions of the clinic are first, service to the 
patient ; then in order, service to the doctor, to the 
student, and to the community. The functions of 
the social service department are given as three ; — 
1. Followup for, a, social relief of patients; b, 
continued treatment; c, protection and care of con- 
tacts and families. 2. Investigation of patients 
applying for admission to clinic. 3. Training of 
nurses and social workers. The relation of the 
social service department to the clinic has not yet 
reached its full and proper development. This 
development requires cooperation and greatly in- 
creased mutual knowledge on the part of the social 
workers and the medical staff of the clinic. The 
work of the clinic, comprising all that is included 
in social and scientific medicine, can best be trans- 
lated to the community through the agency of the 
social service department. 

Epidemiology and Etiology of Influenza. — Al- 
lan J. McLaughlin (Boston Medical and Surgical 
Journal, July 1, 1920) says that it is probable that 
influenza is a disease of great antiquity, and that 
the cause of the world wide pandemic and interpan- 
demic outbreaks is the same. With a strong pre- 
dilection for the winter months we have influenza 
with us every year — and in retrospect we can detect 
in the mortality statistics outbreaks reaching epi- 
demic proportions in twenty-two out of the thirty 
years since 1889. In 1918-19 the attack rate varied 
from fifteen to forty per cent., and seemed to be 
highest in the age group five to nine — declining in 
each successive age group except twenty-five to 
thirty-four, which exceeded the rate for the group 
fifteen to twenty-four. The incidence in 1918-19 
was greater in females than in males, and the 
disparity was most noticeable in the ages from 
twenty-five to forty, indicating, according to Frost, 
that the females from fifteen to foi-ty-five were 
either more susceptible or more intimately exposed 
to infection than males of the corresponding age. 
Case fatality in the 1918-19 epidemic was about 
two per cent, and was slightly higher in females 
under fifteen, and very much higher in females 
over sixty than in males of corresponding ages. 
From fifteen to sixty the case fatality was much 
higher in males. There was great variation in forty 
large cities in explosiveness of the epidemic and in 
the severity as measured by the excess death rates 
for the entire epidemic period. There seemed to 
be some correlation between explosiveness and the 
severity as measured by excess death rates — the 
greatest mortality being usually, but not always, in 
cities with a high explosive index. There was little 
consistency in the explosiveness of the two epi- 
demics, 1918-19 and 1920, upon comparing the 
indices in the various cities. Cities with a high 
explosive index in 1918-19 often had a low index 
in 1920. Most cities with a high explosive index 
for 1920 had a low index for 1918-19. Memphis, 
Nashville, and Washington had a high index of 



loO 



MISCELL.IXV FROM HOME 



AXD FOREIGN JOURKALS. 



I New N'ork 
Mf.dual Journal. 



explosiveness in both epidemics. There seemed to 
be some correlation between explosiveness and the 
general death rate and the rates for the four prin- 
cipal caus.es oi death — pneumonia, tuberculosis, 
heart disease, and nephritis. There seemed to be 
considerable correlation between the total excess 
death rates for the epidemic periods and the general 
death rate and the death rates for pneumonia, 
tuberculosis, heart disease, and nephritis. All the 
evidence points to an immunity of relatively short 
duration, probably of months rather than years. 
The etiological cause is unknown. There is not 
sufficient evidence to warrant the view that the 
bacillus influenzae is anything more than a second- 
ary invader. The claims for a filterable virus are 
strong, but much additional work will be necessary 
to make certain many things which are now only 
possibilities. A survey of the whole field and of 
all available literature has convinced the writer that 
while further epidemiological studies will have 
great value and be of intense interest, they will not 
furnish a solution of the problem. We must have 
more intensive, comprehensive and sustained 
laboratory research, using the body fluids and 
secretions of influenza patients for material, if we 
hope to solve the problem and secure the biological 
aids which we now lack for the prophylaxis and 
treatment of influenza. 

Unusual Cases of Mastoiditis. — liarold Hays 
{American Joiinial of Surgery, September, 1920) 
says that cases of mastoiditis in New York last 
winter not only reached alarming number.s but 
presented unusual complications of a severe nature. 
In former years it was believed that in ninety per 
cent, of the cases of acute catarrhal and acute sup- 
purative otitis media, where it was necessary to 
incise the drum, recovery took place within a few 
days or a week, and that in only a small percentage 
of these cases did mastoiditis actually develop. Last 
winter, however, these figures were reversed ; mas- 
toiditis developed in the majoi-ity of the cases of 
acute otitis media. In most of these cases acute 
suppuration of the middle ear developed, without 
any previous> warning. Some of them occurred 
after influenza, but the majority of them occurred 
where there was nothing to make one think that 
there was going to be any real trouble. In the 
majority of these cases, the drums were incised as 
soon as any bulging occurred, and it was the 
author's invariable practice to have a culture made 
from the discharge from the incision as soon as 
possible. These cultures showed a variety of or- 
ganisms. In the majority of cases, particularly 
those in which there were complications, the or- 
ganism was the streptococcus hemolyticus. The 
blood counts in these cases ranged from 14,000 to 
25,000 white blood cells, with a polynuclear count 
from seventy-five to ninety per cent. The fever 
was usually high, but in some of the cases where, 
although the temperature might have been high at 
the onset of the trouble, after the drums were in- 
cised, it generally went down to normal, and 
remained there regardless of whether the mastoid 
was involved or not. In two cases the temperature 
had risen to 106°, and after the drums were incised, 
gradually went down to normal and stayed normal. 



However, the symptoms of mastoiditis progressed 
until it was imperative to operate, and in both in- 
stances a total destruction of the mastoid cells was 
found. The author reported several interesting cases 
and presented the following conclusions: 1. The 
number of cases of mastoiditis has become alarm- 
ingly large since January, 1920. 2. The majority 
of infections have been due to the streptococcus 
hemol>'ticus. Although this organism is morpho- 
logically the same as ever, there is evidence that its 
virulence is greater and that it has a peculiar ability 
to destroy bone beyond the mastoid region. 3. The 
zygoma, beyond the cells usually found, has been 
found diseased in many cases, causing a severe 
radiating neuralgia of a supraorbital character. 
4. Symptoms simulating a localized meningitis, in- 
definite in nature and sometimes suspicious of men- 
ingitis lethargica (sleeping sickness), have been seen 
in many cases. 5. Examination of the eyegrounds 
is most important in suspected cases of sinus throm- 
bosis. A choked disc often is found on the side on 
which the sinus is involved. 6. Laboratory exam- 
inations are of the utmost importance. 7. Trans- 
fusion (by the simple Unger method) was a life- 
saving measure in two of the cases cited. 

Lethargic and Myoclonic Forms of Epidemic 
Encephalitis. — Pietro Boveri (Journal of Nervous 
and Mental Diseases, May, 1920) reports cases of 
epidemic encephalitis presenting the unusual symp- 
toms of myoclonic convulsions, both rhythmic and 
partial, as though produced by an electric current. 
Dubini in 1846 described a form of disease termed 
by him electric chorea, a term which in years since 
has been applied to many manifestations which 
should probably be better classed as typhoid or 
malarial fevers or Jacksonian epilepsies. The dif- 
ferent symptomatology between the lethargic and 
the myoclonic types of encephalitis suggests a dif- 
ferent pathological localization of the virus. In 
the lethargic form the localization is particularly 
on a level with the central peduncles and the locus 
' niger. The writer raises the question whether in 
the myoclonic type of the disease the centres might 
not be localized in the opticus thalamus transitorily. 
The absence of lethargy, together with the striking 
myoclonic convulsions, justifies the differentiation 
of a myoclonic type of epidemic encephalitis as 
distinct from the lethargic type. 

Relapsing Fever. — W. K. Calwell (Lancet, Octo- 
ber 16, 1920) studied 125 cases of relapsing fever 
among British and New Zealand troops in Cairo. 
Sixty-nine of the cases were of the North African 
type, the rest of the Palestine type. The former, 
which has been described by Sandwith and Balfour, 
is treated with salvarsan. The latter is often at 
first diagnosed as malaria or pyrexia. Fever and 
relapses occur to as high a number as thirteen. 
Afebrile periods lasted from two to twenty-seven 
days, and the longer the interval the rarer the 
relapses. Pneumonia, facial paralysis, and jaun- 
dice may complicate cases, but only one of fifty- 
six cases were fatal. General prophylactic measures 
should be taken ; salicylates and aspirin are used 
for rehef of pain ; fluid diet prescribed. Kharsavan 
in 0.6 grain doses is a specific largely preventing 
rclai^scs. The disease is tick borne. 



Proceedings of National and Local Societies 



AMERICAN PEDIATRIC SOCIETY. 
Thirty-second Annual Meeting, Held in Highland 
Park, III., May 31, June 1 and 2, 1920. 

The President, Dr. Thomas S. Southworth, of New York, 
in the Chair. 

( Concluded from page 87 .) 

A Twenty-four Hour Schedule for Boys. — Dr. 

Richard M. Smith recalled that in a previous com- 
munication he drew attention to certain funda- 
mental principles with reference to the care of the 
health of school children, and pointed out lines for 
the further extension of health supervision. A 
table had been prepared showing the proper distri- 
bution of the boy's time during school hours be- 
tween study, activity and inactivity. They were 
now convinced by a further use of the table that 
it gave a correct distribution of the boy's time. 

The parent, the physician, and the teacher were 
together responsible for the child's life, and no part 
of that life could be arranged intelligently without 
the cooperation of all three individuals. For in- 
stance, the child's physical environment, such as 
buildings and fresh air, was dependent, not only 
upon the proper sanitation of the school building, 
but upon the room he slept in. His nutrition was 
maintained not only by the school lunch and the 
dinner received at school, but also by the breakfast 
received at home. His. educational work in school 
must be arranged, bearing in mind not only the 
studies necessary for the school curriculum, but 
also whether or not he was doing work at hoine, 
such as music and languages. His exercise was 
made up of what he did at home in the afternoon 
quite as much as of the carefully arranged athletics 
at school. 

A Study of Breast Feeding in the City of Min- 
neapolis. — Dr. Julius P. Sedgwick, of Minne- 
apolis, described a plan to encourage breast feeding 
that he had been instrumental in putting into effect 
in Minneapolis. The work fell into two parts : 
1. That of maintaining breast feeding. In their 
private work and in the clinic they had been using 
certain principles described in a paper presented 
before the American Medical Association in 1917 
for maintaining and increasing the supply of breast 
milk." They wished to see if these principles could 
be applied on a larger scale. 2. They wished to 
ascertain what statistical results they could show by 
a wider application of these principles as to the 
proportion of mothers nursing their babies and the 
effect on infant mortality. In order to maintain 
and promote the milk supply they had used the well 
known methods, paying special attention to that of 
making a demand upon the breast by expression. 
This he felt was the most important factor in main- 
taining the supply of breast milk, and had enabled 
them to accomplish a great deal. The technic used 
in the expression of the milk was not that of going 
over the whole gland tissue and using massage, but 
simply consisted of emptying the sinus back of the 
colored areola. Expression was used for premature 



infants, where the mother had poor or inverted 
nipples, sore breasts, or, if for any reason tiie baby 
could not take the breast and they wished to main- 
tain the milk supply. 

The other part of carrying out their plan con- 
sisted in reaching the public. This they had done 
by gaining the cooperation of the medical profes- 
sion, the health department, the Infant Welfare 
Society, and that of prominent citizens. The mother 
of every baby born in Minneapolis during the year 
was either seen by a representative of the organ- 
ization or reached by mail or telephone. Each 
mother was given information and literature. She 
was followed and seen or heard from every month 
or oftener if necessary. As a result of this work 
ninety-six per cent, of the babies born in Minne- 
apolis were breast fed, and the mortality had 
dropped from seventy-one to sixty-five per cent, 
for that year. 

The Fate of Subcutaneously Injected Red 
Blood Cells. — Dr. Rood Taylor, of Minneapolis, 
stated that former experimental work had proved 
that subcutaneously injected red blood cells were 
quaHtatively capable of reaching the recipient's cir- 
culation. In this work the usual clinical methods 
were employed to show that the subcutaneous injec- 
tion of large amounts of homologous citrated blood 
into infants produces a decided hemoglobin increase. 
Using Ashby's m.ethod of differential red blood cell 
counting, the writer then determined that following 
subcutaneous injection of homologous citrated blood 
there was no marked absorption of injected cor- 
puscles into the recipient's circulating blood. 

The Circulatory System in Nutritional Dis- 
turbances. — Dr. W. McKiM Marriott, Dr. H. 
McCuLLOUGH, and Dr. K. Utheim, of St. Louis, 
prepared this contribution, which was presented by 
Dr. Marriott. He stated that in that particular 
nutritional disturbance known as athrepsia or maras- 
mus, it was very evident clinically that some changes 
in the circulation had occurred. This was recog- 
nized by the low surface temperature, slow pulse, 
and grayish color of the skin. It had seemed de- 
sirable to estimate quantitatively the degree of cir- 
culatory changes and, if possible, to determine the 
cause of the changes. In measuring the circulation 
they had used the colorimetric method of Dr. G. N. 
Stewart. Before applying this method to infants 
they had applied it to animals and compared the 
results with those obtained by the Ludwig-Stroh- 
niiihr. The method was easily applied to infants. 
In a series of twenty-nine normar infants the aver- 
age flow of the blood was 17.2 c. c. to the 100 
c. c. of arm a minute. In applying the method 
to thirty-five athreptic infants the volume flow of 
the blood was found to be greatly diminished, some- 
times being as low as one or two c. c. a minute. 
As these infants improved the volume flow of the 
blood increased, in some instances becoming normal. 

The next question was in regard to the cause 
of the decrease in circulation. One cause of 
diminished volume flow of the blood was known 



132 



I'ROCBEDIXGS OF NATIONAL AND LOCAL SOCIETIES. 



[New York 
Medical Journal. 



to be a decreased blood volume. The next step was 
to determine the blood volume of normal and 
athreptic infants. In a series of normal infants 
the average blood volume was 9.1 per cent, of the 
body weight, the variations being from 8. to 10.8 
per cent. The average blood volume of a number 
of athreptic infants studied was eight per cent, 
of the body weight. One showed as low as 4.8 
per cent. As adipose tissue is a relatively non- 
vascular organ, none would expect a thin infant 
to have a larger amount of blood per kilo of body 
weight than a fat one. They found the reverse 
to be often the case. This indicated definite de- 
crease in the volume of the blood. The lowered 
tdood volume was sufficient to account for the low 
volume flow in at least some of these infants. 
Other factors, however, seemed probably to be 
operative. The peripheral volume flow of the blood 
would be increased if capillary or arteriolar con- 
striction had occurred. They found such a constric- 
tion to occur in these mfants. This was shown 
by the fact that there was a piling up of the blood 
corpuscles on the capillary side. Blood obtained 
by a prick in the skin of these infants showed a 
distinctly higher hemoglobin in red and white cell 
counts than blood obtained directly from the veins. 
This constriction of the arterioles leads to poor 
peripheral circulation and probably to the gray color 
of the skin. 

They considered the arteriolar constriction as a 
compensatory mechanism to maintain blood pres- 
sure when the blood volume was diminished. 
They found this mechanism ordinarily sufficient to 
maintain the blood pressure as they very rarely 
observed low blood pressures in the athreptic in- 
fants studied. Having considered the changes in 
the blood and in the vessels, they next turned to 
a consideration of the heart muscle itself. This, 
as might be expected, would atrophy with the rest 
of the body, but at postmortem very little change 
in the heart muscle could be made out. It is pos- 
sible, however, that functional changes might occur. 
To determine whether or not such was the case, 
electrocardiograms were made, and in a certain 
number of the infants definite changes in the 
functional activity of the heart muscle were demon- 
strated. The variations from the normal most 
frequently observed were low amplitude of all waves. 
With improvement in the clinical condition of the 
patients the form of the electrocardiograms changed 
and this suggested that the alterations in the heart 
muscle were functional rather than organic. They 
suggested that poor circulation through the coronary 
arteries was in part responsible for the changes, 
a vicious circle being thus established. 

Some experiments were done on animals in an 
attempt to reproduce the athreptic condition. After 
a period of complete starvation the blood of rabbits 
was found to be definitely decreased, and also the 
volume flow. When the animals were again fed 
they maintained a constant weight for a consider- 
able period of time until the blood volume slowly 
increased. After this the process of repair became 
more rapid. In some animals the blood volume 
did return to normal, and these animals failed to 
recover their weight and finally died. 



The Calcium Magnesium Phosphorus Balance 
in Children Subject to Convulsive Disorders. — 

Dr. B. Raymond Hoobler. of Detroit, presented 
a study of a group of children subject to convul- 
sive disorders, none of whom gave a history of 
epilepsy in the family. Normals of the same age 
and weight were used as controls. The balances 
for phosphorus, calcium and magnesium were deter- 
mined. In general, it was found that the retention 
of these minerals was considerably diminished in 
children subject to convulsive disorders, though in 
no instance was the balance lowered in all three. 
In convulsive disorders of this type a search should 
be made for some mineral deficiency, either in 
calcium, magnesium, or phosphorus, and if such a 
deficiency is found an attempt should be made to 
bring it up to normal. 

Electrocardiography in Children. — Dr. AIax 
Seham and Dr. Frederic W. Schlutz, of Minne- 
apolis, presented this paper, which covered the 
physiological peculiarities of the normal electro- 
cardiograms of children of all ages, including the 
premature, from one hour to thirteen years ; the 
pulse periods in fiftieths of a second in all ages ; 
the transmission time of both auricle and ventricle, 
and electrocardiograms in diseases peculiar to child- 
hood. The electrocardiogram at birth was found 
to be constant, all the newborns, twenty-two in num- 
ber, showing constant curves. A right ventricular 
preponderance was characteristic, showing a deep S 
and a high R^. This form persisted during the first 
three months. During the fourth month the S 
became smaller than the R in Derivation 1, sig- 
nifying a change from right to left ventricular 
preponderance. From the fourth month to the end 
of the first year it gradually changed to the adult 
type. From the first year on the adult charac- 
teristics persisted. In the premature the form of 
the electrocardiogram was incomplete. All of the 
deflections with the exception of S were not seen. 

The pulse in newborns was regular, as shown 
by electrocardiograms. Sinus' arrhythmia was not 
complete until the school age. From this time until 
puberty it occurred in about fifty per cent, of nor- 
mal children. By measurement of the P-R and 
R-T intervals the transmission time could be accu- 
rately studied. The average P-R in the newborn 
was 0.10 of a second; from two to five years it 
was 0.12 of a second, and from six to thirteen 
years it was 0.28 of a second. This included the 
Q-R-S period, which in the respective ages was 
from three hundredths to nine hundredths of a 
second. The electrocardiogram was likewise of 
great aid in the diagnosis of abnormal conditions. 
A study of twenty-two cases of congenital heart 
lesions, two of which came to autopsy, showed that 
only in cases in which the right side of the heart 
was involved, especially in pulmonary stenosis, was 
there a characteristic right ventricular preponder- 
ance. In seven of eleven drop hearts, all of which 
were confirmed by x ray, the ventricular complex 
in lead one was unusually low. Three hundred 
cases were studied, including those showing the 
exudative diathesis, decomposition hypertrophy of 
the heart when unassociated with heart murmur, 
spasmophilia, or tuberculosis of the lungs. 



New York Medical Journal 

INCORPORATING THE 

Philadelphia Medical Journal ;t Medical News 

A Weekly Review of Medicine, Established 18Ji.3. 

Vol.. CXI!!. No. 4. Ni:\V VoliK. SATURDAY. .lAXrAUY 22. 19:21. Whole No. 2109. 

Original Communications 



MODERN COMMENTARIES ON 
HIPPOCRATES. 
The Pneuma and the Books of the 
Hippocratic Corpus. 
By Jonathan Wright, M. D., 
Pleasantville, N.'Y. 
In approaching the question of doctrinal indica- 
tions in the works of Hippocrates from the view- 
point of their historical development, I am embar- 
rassed to find myself confronted by the ciuestion of 
the authenticity of the separate books. In previous 
articles dealing with the theory of the pneuma, I 
have committed myself to the belief that the dia- 
logues of Plato and the works of Aristotle were 
written before many of the treatises found in the 
various editions of the Hippocratic Corpus. I find 
myself quite incompetent to judge, not only of the 
value of much which Galen has said about the sub- 
ject, but especially of tiie value of the many paleo- 
graphic, philological, and archeological arguments 
advanced by writers in less remote periods, from 
Tiis times to our own. I have been guided chiefly by 
Littre as to what are the genuine and what are the 
spurious works, since all the works, at one time or 
another, by one editor or another, for one reason 
or another, have been ascribed to the authorship of 
Hippocrates II, son of Heraclides and Phsenerete, 
.^ui^posed by most authorities to have been born in 
Cos about 460 B. C, but by some writers asserted 
to have lived at an earlier or a later time than this 
would indicate. The length of his life and the place 
lit his death are involved in still greater doubt. 
There is hardly a treatise of them all which has not 
liien declared of doubtful origin, and even the most 
commonly discredited tract has rarely a surer claim 
to any known successor or predecessor for its origin. 
Despite my own helplessness, I confess I am not 
always filled with implicit trust in the judgment of 
the great French savant, whose work, now more 
than three quarters of a century old, is by all odds 
the most trusted. 

Unable to judge of the weight of many of the 
arguments advanced by the critics, nevertheless I 
have allowed myself to be influenced by those which 
seem to me capable of impressing the casual reader. 
•Accepting the date 460 B. C. as that of the birth 
of Hippocrates, that of Plato as 430 B. C, that 
of Aristotle as 384 B. C, we are justified in believ- 
ing that any outstanding anatomical fact known ta 
Hippocrates, it would seem, was known also to 



the latter two. The acquaintance of Plato and 
Aristotle with the knowledge of their times and 
their works, which have come down to us. were so 
extensive and of such a character it is impossible, 
apparently, that it would not only have been known 
to them, but improbable that they would have passed 
it over in silence. It is not true, as we would infer 
from some histories of medicine, that in the genuine 
works of Hippocrates there is no mention of the 
artery in apposition to the vein. The word does 
occur in Articulations, a book undoubtedly genuine, 
and refers to a bloodvessel, but there is no indi- 
cation of anything but a nominal differentiation 
from a vein. In Plato and in Aristotle, so far as 
I know, the name artery as indicating a bloodvessel 
does not occur. I do not know how to account for 
this. Galen says that Euryphon, a Cnidian older 
than Hippocrates and of course something like a 
hundred years before Aristotle, made the distinction, 
although Wellmann thinks Diodes, a contemporary 
of Aristotle, first made it. I cannot see much 
plausibility in the suggestion that where the name 
occurs in a genuine book like Articulations and in 
other treatises, supposed to be citations from some 
of the genuine books, although written perhaps by 
authors contemporary with Aristotle, it is the inter- 
polation of a copyist. There is a similar difficulty, 
too, with the word muscle. Both artery and muscle 
are mentioned in books, which in no way, other than 
the names, refer to anything indicating a discrim- 
ination of the former from other bloodvessels or 
of the latter from other flesh. If we find in Aris- 
totle no mention or no explicit discrimination be- 
tween artery and vein, we cannot but believe that 
the Father of Medicine, much older, was also in 
ignorance, and that the passages in his writings 
containing such mention are spurious. 

These three men furnish us with the most exten- 
sive and the most exhaustive (I was going to say 
with the only) account of the philosophical and the 
medical theories and facts, extant in the Greek world 
from the birth of Hippocrates, through the life of 
Plato to the death of Aristotle, and there are some 
facts, one would think, to which not one of them 
would have failed to allude, if known to him. The 
separation of the artery from the vein is one. I 
cannot see that Galen takes any account of this 
chronology in his discussion as to the authenticity 
of certain books of Hippocrates. 

There are other facts which have been adduced 
against the validity of the only example I have here 



Copyright, 1921, by A. R.. Elliott Publishing Company. 



134 



IV RIGHT: COMMENTARIES ON HIPPOCRATES. 



[New York 
Medical Journal. 



introduced of this critical discussion, which since 
Galen's time has centered around the question of 
the authenticity of the separate Hippocratic treatises. 
As to the definition of artery and vein, I have thus 
far broached the subject because in the previous 
paper, more particularly concerned with Aristotle, 
we also came squarely against it in the statement of 
his knowledge of the ultimate bronchial divisions 
and the pulmonary circulation. We saw how vitally 
involved was his doctrine of the pneuma with the 
anatomical relation and the physiology of the great 
vessels. We must think he surely would have said 
more, if more had been known to him. Yet Littre 
. can find no argument against the greater knowledge 
of Hippocrates. 

If I have exposed sufficiently a point of valid 
criticism of a kind constantly met with in the writ- 
ings of those who have commented on Hippocrates, 
I may be permitted to point out another which, on 
the other hand, is sometimes given more weight than 
it deserves in the literature of the subject. There 
are two kinds of men who gain recognition in 
scientific medicine; indeed, I suppose, in other 
branches of science also. In fact, the types are 
recognizable in walks of life which are not scientific 
at all, and though we are not primarily concerned 
with these the conventional idea of that form of 
group leader who tells people that which they wish 
to hear and are capable at once of understanding, 
in the way of illustration, will serve us well enough. 
He floats with the tide, he turns his sail to every 
favoring breeze, however temporary. His weather 
vane points, not necessarily to the horizon of truth 
at all, but, mindful of the opinions of bis fellows, 
to that part of it from which the wind of popular 
interest is blowing. This political huckster is the 
type of the man of science who is concerned only 
with propagating self evident truths or already widely 
held beliefs. He does this with an assurance that 
amounts often to insolence, but he founds no new 
ones. He is the champion of the obvious or the 
apparent, of the pneuma or of any prevailing fad 
today — it is better to let the reader fill ,in the name 
of that himself — but in his defense it should be said 
that he, too, has his usefulness in his profession, 
whatever it may be. With industry in it he reaches 
the summit of that kind of ambition which he has 
been able, from his mental limitations, alone to 
nourish. His exhortations and dissertations are 
largely reflex, he thinks with his spine, the product 
is the reflection of the mass in which he is immersed. 
From such an individual issued some of the books 
of the Hippocratic Corpus. 

On the contrary, in others, however far from the 
truth we may know the author to be, we note Hip- 
pocrates carefully, painfully, modestly weighing the 
evidence pro and con — experience is misleading and 
judgment difficult — the doubt which bespeaks the 
occupation of a mind too absorbed with the problems 
of life to exploit its commonplaces in the interest 
of his fame is found on every page. Not by any 
means on every page, but now and again we get 
a flash of light that shines across the ages. The 
good the other man does lies buried with his bones. 
We meet him so often in the Hippocratic Corpus 



only because some Alexandrian captain of marine 
industry has foisted his writings on the librarian 
by bluff as the work of the great Hippocrates (6). 

Now it is quite impossible for the diligent and 
intelligent reader, as the work of Hippocrates is 
, transmitted to us, not to be struck with thoughts 
like these, but he should beware of setting them up 
as a canon of criticism. They but reflect his own 
limitations. I have not infrequently seen some of 
the aphorisms of Hippocrates lauded to the skies 
by men whose common sense I am occasionally 
compelled to respect, which I regard as an insult 
offered to the understanding of the Father of Medi- 
cine, either as a 'physician or as a man of sense, 
but I recall how often I have had occasion on the 
other hand to think a thing pretty good which a 
critic, vastly more learned than I, considered be- 
neath the intellectual powers of Hippocrates him- 
self. Nevertheless, it is a fact that in most of the 
books, which from other internal and external 
reasons are supposed to be genuine, we find the 
theory of the pneuma and the theory of the humors 
but casually mentioned and cautiously applied, or, 
as in Ancient Medicine, subjected to a raking criti- 
cism which must have seemed cranky and perverse 
to the good mixer who wrote the Winds or the 
Humors. 

1 sometimes wonder if this wide extended hetero- 
geneity is not responsible for some of the fame 
of Hippocrates. It appeals by virtue of it not only 
to the man of science but to the man of the street, 
not only to the philosopher but to the fool, not 
only to the selfcontained philosopher but to him 
whose sphere of usefulness is the propagation of 
the work of more original men. Every advance in 
knowledge which can, by popular agitation, be im- 
pressed on the people owing to the simplicity in 
the processes of thought involved, to the earnestness 
with which it is urged, or to the manifest advan- 
tages derivable from its application, is sure, because 
of these things, to pass through an epoch of gross 
exaggeration and distortion, both in discussion and 
in the deductions made from it. The application 
of the latter in practice is usually carried to ridicu- 
lous extremes, as it doubtless was at Athens when 
Aristophanes was writing The Clouds. Oblivion 
and neglect of the kernels of truth such a fad often 
contains are then the regrettable consequences of 
this hotbed forcing of a medical belief, based on 
halfbakecl theory and insecure facts, and urged with 
all the arrogance of those who derive their beliefs 
from the authority of. others rather than from their 
own resources of thought and action. 

Let the reader turn to the tract on the Winds or 
the Pneuma — the winds without, the pneuma within 
the body. Its subject is the fresh air fad of Athens 
in the time of Hippocrates, having been ascribed to 
Diogenes Apollonius, or, perhaps, if at a later period, 
it may have been written in that era of Alexandrian 
research when the great wave of new facts was 
sweeping over the world of ancient philosophy and 
annihilating its poise of intellect. From what I 
iiave said above the reader will easily understand 
why no critic loyal to the art is eager to fasten the 
authorship of it on the Father of Medicine. 



January 22. 1921.] 



Jl- RIGHT: COMMENTARIES OX HIPPOCRATES. 



135 



"All maladies are gf the same nature ; they differ 
only in their location. . . . However, there is never 
but one form and the cause is always the same. 
... I am going to show that all diseases liave their 
origin and proceed from (the pne^ma) . . . fever 
. . . inflammation . . . colic . . . bellyache ... all are 
caused by the passage of the pneuma . . . flux not 
only of the bowels but of the lungs — hemoptysis 
. . . ruptures . . . dropsy . . . apoplexy . . . epilepsy 
— in fact the winds are the chief factors in all 
diseases" — the air outside the body — the pneuma 
within. 

That is the skeleton outline of an obsession which, 
I suspect, followed the study of aerial phenomena 
successive to the demonstration by Empedocles of 
the materialistic nature of the air. I conjecture 
this book, though not by Hippocrates himself, may 
have been of the Hippocratic era because the theory 
of the scientists of the Nature Philosophy was 
impressed at this time on the fickle and fun loving 
Athenians by Anaxagoras, and probably by Diogenes 
Apollonius, both of whom seem to have incurred 
the animosity of the people. How much of this 
was an outcome of, or how much resulted in, the 
savage ridicule Aristophanes cast upon Socrates 
and the sophists we can only conjecture. We see 
him making fun of the vortex of the atomic theory 
specifically. The air monism of Anaximines we 
see exciting his ridicule, but it was misdirected when 
applied to Socrates, who in Plato's portrayal, him- 
self jeers at Anaxagoras and Heraclitus. Socrates 
was pilloried by Aristophanes in the Clouds or hung 
as near them as possible on a high wall on the stage, 
sniffing the pure air, and he as well as all the players 
were endowed with long noses so they could sniff 
up as much of it as possible. 

A generation ago a daily paper in New York, 
with large headlines, in jovial humor, drew atten- 
tion to the inference to be drawn from the enthu- 
siasm of a young niedical author who had pointed 
out the filtering and warming and moistening of the 
inspired air in the physiology of nasal respiration. 
The wit of the press relieved the tedium of scientific 
argument by discoursing on the advantages of 
having a long nose. Doubtless the reporter was 
innocent of any knowledge of Aristophanes's old 
joke, but he anticipated by a decade or so that era 
of faddism on the subject of fresh air which has 
suffused popular science since, and which has to 
some extent obfuscated that of the hierarchy of 
science itself. To some such era as this I 'am dis- 
posed to think we may venture to ascribe the pub- 
lication or the composition of this Hippocratic book 
on the Winds. The author evidently had to meet 
some criticisms as to the morbid manifestations of 
the pneuma. "Why," they will ask me, perhaps, 
"are not all animals affected by it? Why do these 
diseases attack one case?" "Because," I would 
reply, "body differs from body, one kind of nature 
from another, one kind of food from another. For 
the same things are neither always alike suitable or 
harmful to every kind of an animal ; some work 
weir, some work evil." Introducing thus a host of 
additional etiological factors he seems unaware of 
them. That one thing, the pneuma, dominates his 
whole mentality. He uses a word familiar to us, 



but he docs not even think of bacteria: "When the 
air is infected with miasms, which are hostile to 
mankind, men become sick." Then, becoming em- 
barrassed, how natural it is to find him taking refuge 
in mere tautology. "When, on the contrary, the air 
is unsuitable to some particular kind of animal, it 
is that kind of beast which is struck." The pro- 
fundity of this remark is quite modern as well. 
It is a sense of humor that is lacking in us when 
we talk like that. 

The Regimen in Acute Disease is attributed both 
by Galen and by Littre to Hippocrates, but the 
appendix, according to both, is by a later and a 
weaker hand. In it we find in several places a 
reference to an etiology which includes the stoppage 
of the air in the veins. Some disorder of the 
humors, some lack of equilibrium, perhaps, in their 
qualities or quantities, is the prime factor which 
works on the system through interference with the 
pneuma. In The Sacred Disease, not usually 
ascribed to Hippocrates himself, though Adams in- 
cludes it among the genuine works, but evidently 
if not his the work of a disciple better grounded 
in anatomy, we get a conception which is in the 
direct line of inheritance from the one in the 
Papyros Ebers. "By the veins we take in the 
greater part of the air, for they, too, are the breath 
organs of our body, which carry into us the air. 
They distribute it everywhere by means of the little 
veins, then they exhale it, having thus brought in- 
vigoration." This I think is undoubtedly a trace 
of the doctrine of the transpiration through the skin 
which we find elaborated in one of the fragments of 
Empedocles, but I do not know why Wellmann 
should attribute to the latter the statement that 
epilepsy arises from a change in the winds. To 
Alcmaeon we with better reason may attribute the 
teaching insisted on in this book that the brain is 
the seat of the intelligence. We may see in these 
things the influence of the Sicilian School, but it is 
made extremely doubtful by Littre that this tractate 
is to be considered as coming from the hand of 
Hippocrates himself. It is not at all sure from 
anything we can find in those books, more surely 
genuine, that he actually shared this idea of Alcma;on 
about the brain, though he did undoubtedly share 
in the conception of Alcmseon's which looks upon 
disease as a loss of that equilibrium in the elements 
which obtains in health. This very popular idea 
was associated with that of beauty or symmetry of 
form not only by Plato but by the Stoics and many 
centuries afterward by Galen. It had such a 
wide affiliation with geometry and the science of 
number and with the fundamental tenets of the 
Greek theory of art that we are scarcely warranted 
in thinking of Alcmaeon or of any other Greek, 
however early, as originating it, but we cannot yet 
trace further back than Alcmaeon the correct notion 
as to the function of the brain. We ^may suspect 
the simile of an equilibrium as the state of health 
came like the pneuma from Egypt but not the local- 
ization of the cerebral functions in the brain. 

In the Nature of Man, one of the spurious Hip- 
pocratic books, according to Littre, we again find a 
statement which implicates both the pneumatic and 
the humoral theories in the explanation of diseases 



136 



ir RIGHT: COMMENTARIES ON HIPPOCRATES. 



[New York 
Medical Journal. 



which "come, some from the diet and the manner 
of the diet, others from the air," — from the latter 
those diseases we call "epidemic." To this word 
in the Greek no suspicion of infection or contagion 
as yet attaches. It was a loose term equivalent to 
the prevailing diseases. The // Epidemics, which 
seems to be made up from extracts from other books 
in the Corpus, some genuine, some spurious, and 
the Aliment, with which I have dealt elsewhere, 
speak of the air as a food. Littre's comment on 
this is that this conception involves that of varia- 
tions in the air giving rise to disease as do variations 
of the food in the digestive tract, the air acting on 
the respiratory passages and upon the blood vessels, 
both of which take it in. In the book on the Nature 
of tlic Bones, and also in the little tract on the Heart, 
we get further hints of an anatomy originating with 
that of the Papyros Ebers, but nevertheless in both 
books we perceive a decided advance over the 
anatomy of the supposed genuine books of Hippo- 
crates. In the latter there is a similarity in the 
conception to that adopted by Aristotle. 

In resume of the series of essays in which this 
belongs, I may .say I have drawn attention ( 1 ) to 
the ideas of that typical primitive group who stood 
around the dying savage. In every ethnic origin 
that scene was enacted, and the impressions made 
on the mind of man became the possession of them 
all. It was the breath which was the animating 
soul of man. It led the materialistic Egyptians (2), 
the more or less direct heirs and to a large extent 
the descendants of the African tribes with whom 
they had always been in contact, to the conclusion 
that the pneuma, in order to accomplish its mission, 
must penetrate to the uttermost ramifications of 
structure in the animal framework. As there were 
demonstrably channels through the nostrils and 
buccal cavity to the chest, so these channels and 
their communicating branches must lead the pneuma 
to the contracting finger or the marching foot, to 
the beating heart and the gastrointestinal tract, 
rumbling in the abdominal cavity. The mummy 
maker found many channels: the trachea, the blood- 
vessels ; many cavities : the heart, the bladder ; many 
tubes : the hepatic, the renal, the openings of the 
nasopharynx, through one of which passes the breath 
of life and through the other the breath of death; 
the anus, through which passed the flatus and the 
feces. You could feel the pneuma beating in the 
heart and in the bloodvessels wherever the hand 
was laid on them. You could hear it in the bor- 
borygmi of the stomach, and bowels, and in the 
respiratory sounds. 

We are at the present time more able than 
formerly to be assured how these thoughts were 
exchanged throughout the civilizations which bor- 
dered the IV^cditerranean Sea. Plato and Solon 
traded in oil with Egypt; Pythagoras, Herodotus 
and Democritus, and many others, travelled there. 
Political exiles fled across the sea from one con- 
tinent to the other. Prehistoric commerce and con- 
quest evidently went on for thousands of years 
before Hecataeus wrote, and before the pages of 
Herodotus were filled with the Greek characters 



which have been preserved for ;.is. It is supposed 
by some that the Berlin Papyrus, a transcript of 
notes from the Ebers manuscript, and others, was 
known to (ialen. The anatomical learning, which 
was stored beneath the feet of the god Anubis five 
or six thousand years ago, surely passed into the 
Greek world, and the germs of philosophy, already 
alive in the more ancient civilizations, were the in- 
heritance of the nature philosophers on the Asiatic 
shores and the ^gean Islands. The enormous 
expansion these received from the later Greeks has 
been the wonder of the world ever since. Out of the 
Egyptian fermentations grew many ideas found in 
the Homeric poems. The Poem of Gilgamcsh, in- 
calculably older, the Rig Veda, perhaps contem- 
porary, the Zend Avesta, all contributed their 
fructifying waters to the ocean of human thought 
spread out in the annals of the golden age of Greece. 
We have found (3) in the Iliad and the Odyssey 
that conception of the soul, which is identified with 
the air or the pneuma and which is essentially that 
of primitive man. We have seen it appearing under 
modified forms here in several of the later books of 
the Hippocratic collection, and we have also seen it 
idealized^ by Plato (4) and accepted by Aristotle 
(5). 

In broad outlines they all led naturally to the evo- 
lution of the two leading doctrines which dominated 
the science of medicine for thousands of years, but 
Hippocrates the Great was not led away from 
realities by them. Both pneumatist and humoralist 
theories survived the pressure of new anatomical 
facts, revealed by the Alexandrians, for more than 
fifteen hundred years. It necessitated another on 
slaught of anatomical revelations slowly and surel 
to banish these particular blights of theory, in thei 
ancient aspects, from the path of progress, but they 
still can be found under other forms hidden in 
modern theory, yet not in theories alone as obstruc- 
tion to new knowledge, but as founded on facts 
valid, as we believe. 

BIBLIOGRAPHY. 

In the preparation of this paper the following sources 
were used for reference to the works of : 

Hippocrates: The translations of Francis Adams: H-h- 
pocrates, Genuine Works; E'Littre : Hippocrates. Oeu: res 
Completes. 

Galen: Chutdii Galeni Opera Omnia (Kiihn). 

Aristotle: History of Animals (tr. Bohn) ; Treatises, 
translated by Thomas Taylor, 1805. 

REFERENCES. 

1. Blood and the Soul. New York Medical Journal, 
July 20, August 10 and 17, 1919. 

2. The Blight of Theory. Ibid, December 7, 1918. 

3. The Theory of the Pneuma in Homer. Ibid, May 
22, 1920. 

4. The Anatomical and Physiological Theories of Plato. 
Ibid, July 3, 1920. 

5. The Theory of the Pneuma in Aristotlt^. Ibid. Xo- 
vcmber 27, 1920. 

6. Modern Commentaries on Hippocrates. Ibid, De- 
cember 13, 1919. 



' \Vc know of Plato's tripartite division of the soul. In the latros, 
(loul)tless wrongly ascribed to Galen, the pneuma may be found 
.split in thr.e divisions likewise. 



Jaiuiary 22, 1921.] 



HIGH MAN: TREATMENT OF ACNE. 



1.^7 



THE MODERN TREATMENT OF ACNE. 

By Waltf.r J. High. MAX, M. D., 
New York. 

Until recent years acne has been one of the most 
bafifling skin disturbances to treat, and at the same 
time one of the most serious to leave unimproved. 
This does not imply that the condition is organically 
grave, but it is prone to attack young individuals 
during the age of courtship and, because it is so 
disfiguring, it throws upon the sufferer an unwhole- 
some burden of selfconsciousness. Therefore, from 
the viewpoint of human psychology, it constitutes a 
handicap far in excess of the trivial organic damage 
it does. Its effects accomplish this during its active 
stage, and it is particularly disadvantageous to' young 
women, often inducing in them a state of mind 
approaching melancholia. After the active phase 
is over, the permanent damage done to the skin is 
sufficient to perpetuate in a mild degree the mental 
suffering occasioned during its earlier stages. There- 
fore, the problem of treating acne is important, not 
only because an organic disease must be controlled, 
but because a condition predisposing to subjective 
disturbances is presented. 

Acne begins just before or during the onset of 
puberty, and is characterized by an increased oili- 
ness in the skin, the formation of hyperkeratotic 
plugs in the follicles, and a general subtle sallowness. 
The plugs alluded to are called comedones, and 
these are the starting point of the pustules which 
in turn furnish a further disfiguration. Accom- 
panying these skin changes, which are mainly present 
on the face, chest, and back, are scaling of the scalp, 
and sometimes loss of hair. Associated general 
manifestations are gastric indigestion, usually most 
pronounced as to starches and sugars, constipation, 
slight enlargement of the thyroid gland, coated 
tongue, and, depending upon the character of the 
individual, .selfconsciousness and even melancholia. 
It is probable that the subjective manifestations are 
more likely the result of the eruption than of the 
underlying causes thereof. 

In women the eruption often grows worse in 
relation to the menses. Not uncommonly an in- 
crease of sugar is found in the blood, and the gastric 
contents show a high percentage of acidity with 
markedly increased free hydrochloric acid. An 
analysis of the entire picture reveals the following: 
The skin tends to scale, the 'sebaceous glands en- 
large and secrete excessively, and the secretion can- 
not drain off l)ecause the plugs in tlie follicles 
interfere. 

The underlying causes of the disease are probably 
associated with the profound changes inherent in 
puberty. Inasmuch as puberty cannot be hurried 
or modified by treatment, the main hope of therapy 
lies in an attempt to alter the skin so that the pre- 
disposing features become unable to do any great 
damage. It is necessary, before continuing, to state 
that the formation of pustules is incidental, the 
comedones acting as foreign bodies which make it 
possible for the bacteria in the follicles to become 
active. Thus the indications for treatment are 
twofold: First, the prevention of comedone forma- 
tion ; second, the control of the underlying factors, 



where this is possible. Incidental indications are 
the treatment of the scalp and the expression of 
the pustules and comedones. 

The general treatment consists of regulating the 
diet by cutting down the starch and sugar intake and 
by promoting intestinal function. The latter is 
best accomplished by eating green vegetables and 
stowed fruits, together with the judicious use of 
cathartics, if indicated. If there should be a dis- 
turbance of the internal generative organs, a con- 
dition rarely found in the young, this should be 
controlled. In dieting patients, however, it is ex- 
tremely important to keep up the general nutrition 
and weight. 

The most important indication in local treatment 
is to prevent comedone fonnation. If this can be 
accomplished, pustules will not develop and the 
disease will be automatically controlled, even though 
the predisposing causes are not, for acne cannot 
occur where the skin is normal and the sebaceous 
glands are not overactive. In former days this was 
done with moderate success by the use of sulphur, 
resorcin or salicylic acid in lotions or creams. These 
substances make the skin peel and tend to overcome 
the condition favoring acne. Today this may be 
accomplished more certainly and more precisely by 
the use of the x rays in given amounts. One 
Holzknecht unit applied to the face weekly, for 
from ten to sixteen expo.sures, will cure the average 
case of acne, and if from time to time there .should 
be recurrences, these will yield readily to two or 
three exposures. The x rays work by diminishing 
the function of the skin glands and by diminishing 
exfoliation. Conservatively stated, nine cases out 
of ten can be cured in this fashion. 

Thus it is possible to start treatment when acne 
first appears and before any real damage has 
been done to the skin. No local treatment is neces- 
sary at home. This eliminates the expense and the 
loss of time that the purchase and application of 
drugs involves. In other words, about six minutes 
weekly in a physician's office for from ten to six- 
teen weeks will accomplish more than older methods 
could ever do. 

The cosmetic result is enhanced by :>killful ex- 
pression of the comedones and pustules, and the 
incidence of recurrences is reduced by the use of 
mild antiseptic lotions to the scalp. The employ- 
ment of vaccines, so far as my experience goes, 
promises nothing, for, as already stated, the pus- 
tules are purely incidental and will not develop 
unless comedones are present. It goes without say- 
ing that the general treatment should not be neg- 
lected, for, after all, the disease is a local mani- 
festation of a general disturbance, and more perma- 
nent results are secured by bearing this fact in mind. 
Nevertheless, without the local disturbance, the 
general derangement is incapable of producing acne, 
so that the major indication is the treatment of the 
skin. 

In addition to the foregoing, the patient should 
wash the face with a rich lather twice a day and 
shampoo once a week with some simple soap. Green 
soap is contraindicated. Recurrences take place in 
about one case in four, and are easy to control 
with two or three x ray exposures. This line of 



138 



ROSENHECK: NEUROLOGICAL BACKACHE. 



[New York 
Medical Journal. 



treatment was unsuccessful in only three instances 
out of fifty, and in one of these patients there 
was a marked secondary anemia. Such exceptions 
are indeed rare, and as compared with older methods 
of treatment, the precise one outlined removes acne 
from the group of the serious disturbances of youth. 
780 M.ADisox Avenue. 



BACKACHE DUE TO NEUROLOGICAL 
CONDITIONS.* 

By Charles Rosenheck, M. D., 
. New York, 

Neurologist to the Hospital for Deforrnities and Joint Diseases, 
New York, and the New York Diagnostic Clinics. 

Backache as a distinct neurological manifestation 
holds a subsidiary place in neurological afifections. 
On account of the anatomical proximity of the back 
muscles to the spinal cord the natural presumption 
would be that this symptom would at once obtrude 
itself in the clinical picture as a major symptom. 
The contrary, however, seems to be the case. An 
analysis of the functions of the spinal axis readily 
explains this seeming paradox. Its activities, both 
motor and sensory, are in the main projected at a 
distance from its anatomical location. Pain as a 
s}Tidrome of sensory disturbance is therefore propa- 
gated along distal pathways, although the situation 
of the anatomicopathological lesion is proximally 
located. One must not, however, accept this rule 
as a finality. Distinct anatomical differentiation is 
an essential which is not to be ignored in our 
analysis of the pain syndrome ; for it is a fact known 
to the veriest tyro in medicine that an implication 
of the posterior* spinal root or its ganglia is neces- 
sary to propagate the painful sensation to distant 
anatomical parts. A different view, however, is 
permissible when the dural covering alone is in- 
volved. 

As far as clinical and experimental data are 
available, pathological processes here do not call 
forth painful sensations at a distance. On the con- 
trary, the immediate anatomical structures reveal 
the effect of dural disease; hence we find as a 
major symptom of spinal meningeal affections, se- 
vere and persistent pain in the musculature of the 
back. Backache as a symptom in diseases of the 
spinal cord has evidently been treated rather lightly 
by medical, writers ; for in a thorough search of the 
available literature I was able to find only two ar- 
ticles on the subject which approached it from the 
viewpoint of the neurologist. These were by Lang- 
don and Neustadter, who built up their clinical 
neurological picture on the patient's chief complaint 
of backache. One can readily appreciate why this 
symptom has escaped the attention of our vol- 
uminous medical writers. After all, it is only a 
minor complaint and is readily submerged in the 
far more striking picture of gross motor and 
.sensory disturbances. These defects are more dis- 
tressing to the patient and wholly dominate the 
clinical . picture. 

Incidence. — In an analysis of the clinically recog- 

*Rcad at a nie;-tiiiR of the New York Physicians' Association, 
November 23, IP-'d. 



nizable afifections of the cerebrospinal axi.s, taken 
from the standard textbooks of Starr, Gowers, Op- 
])enheim, Osier, Dejerine, Strunipell and \'on Leube. 
backache as a symptom occurs in thirty per cent, 
of all neurological conditions. This is surely not 
an imposing figure. Obviously it could be in- 
creased greatly if we were to limit our analysis to 
affections of the cord per se. Under this scrutiny 
we will find this symptom as a subjective complaint, 
in all affections of the spinal axis where we can 
definitely establish the etiological relation to hemor- 
rhage, acute inflammatory disease, and new growths. 
Here again the necessity of reiterating that it plays 
a subsidiary role in the symptomatology is permis- 
sible. It is the gross motor and sensory manifesta- 
tions in these affections that at all times control the 
clinical scene. 

Etiology. — The etiological factors involved in the 
causation of backaches in neurological affections is 
to be looked for in those morbid processes which at 
once affect the integrity of the dural covering and 
the dorsal roots. In the main these are to be found 
in acute or subacute infections of the meninges, 
hemorrhage in the cord substance or its dural cov- 
ering, and neoplastic processes. Degenerative dis- 
eases of the spinal cord may cause backache, but 
the pain in these affections is insignificant and must 
be explained more on the ground of interference 
with the patient's . motor activities. Inflammatory 
processes in the dorsal roots and ganglia which 
manifest themselves clinically as herpes zoster will 
quite often be preceded by severe back pains: 

Traumatic neuroses and neurasthenia are particu- 
larly prolific in producing pa,inful and persistent 
backache and are worthy of special mention. The 
underlying pathology in these affections is quite 
obscure and has been the subject of much con- 
troversy. Under traumatic neuroses, the railwa}' 
spine of the older writers, notably Erichsen, held 
full sway. This observer regarded the condition 
as the result of inflammation of the meninges and 
cord. Walton and J. J. Putnam were the first, how- 
ever, to recognize the functional nature of many 
of the cases. To Westphal and his pupils we owe 
the name traumatic neurosis (Osier). Quite re- 
cently the appellation traumasthenia has crept into 
the literature and this to my mind aptly describes 
the condition. It is not an exaggeration of fact to 
say that in contrast to the insignificant role that 
backache plays in orgdnic affections of the nen'ous 
system, the contrary holds true in the traumatic 
neuroses. It is easily the major presenting sub- 
jective symptom in a great number of cases.. The 
imderlying etiology varies with the individual case, 
but in the main trauma and the resultant shock to 
the nerv^ous system are the factors involved. Of 
course great caution must be exercised in insisting 
on the functional nature of a given case, for trauma 
and shock can be so severe- as to seriously com- 
promise the integrity of the cord and meninges. 
Organic changes are the inevitable results and our 
interpretation of the resulting sensory and motor 
phenomena inust be considered in the light of an- 
atomicopathological disturbances. The backache 
of neurasthenia has been observed by clinicians since 
time out of mind and the well known spinal irri- 



January 22, 1921,] 



ROSENHECK: NEUROLOGICAL BACKACHE. 



139 



lability of the older writers has tlchnitely ])Ut a 
stamp on this affection to the present day. The 
etiology of this back pain, apart from the ev,er fas- 
cinating theory of chemicophysical changes in the 
spinal cord, is most likely due to a generalized 
neuromuscular fatigue. 

Pathology.— The pathological processes which 
cause back pain obvioush- var}- and are determined 
by the underlying conditions. Broadly speaking, 
these are hemorrhage, inflammatory afifections and 
new growths. Any one of these morbid states can 
readily aflfect the integrity of the dural membranes, 
spinal roots or ganglia. In simpler terms, pressure 
phenomena or inflammatory reactions in the spinal 
axis are responsible for the pathology of back pains. 
It is unnecessary to dwell at length on the histo- 
pathology governing these processes. Thev are 
selfexplanatory and need no further elucidation. 

Neurological co)id!tioiis producing backache as a 
symptom. — In order that this s}-mptom may receive 
its proper evaluation it will be necessary to enumer- 
ate again the morbid processes affecting the spinal 
axis in which back pain is a subjective complaint. 
These in the main are acute and subacute inflam- 
matory diseases, hemorrhage, new growths, degen- 
erative diseases and the neuroses. The diseases of 
the nervous system which owe their development 
to these initial pathological disturbances will then 
be eniunerated under their respective headings. 

ACUTE INFLAMMATORY DISEASES. 

Epidemic cerebrospinal meningitis. — The back- 
ache in this affection very often ushers in the dis- 
ease. It is indeed a major complaint in a great 
number of cases as long as consciousness is present. 
Its severity is evident by the plasterlike rigidity 
which envelops the entire spinal musculature. This 
rigidity lasts throughout the disease and all spinal 
mobility is practically abolished, the slightest move- 
ment of the spine, either spontaneous or induced, 
increasing the spasm and pain to a marked degree. 
The pain has no localizing characteristics, but is 
diffuse, embracing the muscles in proximity to the 
entire vertebral column. The sufferer describes it 
as gnawing and boring, as if the entire hack would 
be broken by the very violence of the i)ain. 

Acute and chronic myelitis of the cord. — In the 
acute stage of this aff"ection, with involvement of 
the dura mater in the inflammatory process, pain 
in the back is a prominent subjective complaint. It 
comes on early in the disease, but it does not persist ; 
with the appearance of the paralytic phenomena the 
back pains usually subside. The localization of the 
pain depends on the anatomical location of the 
infectious process. This may occur either in the 
cervical, dorsal, or lumbosacral regions of the cord. 
In cases of ascending or dift'use myelitis, the sub- 
jective discomfort may involve the entire back. 
The pain in the.se myelitic conditions is usually 
described as burning. In two cases observed per- 
sonally the patients complained bitterly of an intense 
paresthesia in the back muscles which shifted from 
segment to segment. After the subsidence of the 
acute stage, and when the myelitis passes into the 
chronic phase of the disease, all back pains usually 
di.sappear. 



Landry's paralysis. — Backache in this affection is 
ajiparently not a constant symptom, if one closely 
analyzes the clinical description of the disease. 
Some authors have dwelt with particular emphasis 
on the severe diffuse boring and burning pains in 
the muscles of the back and along the vertebral 
column. Other authors have apparently not ob- 
servecl this symptom or have ignored it in the 
description of their cases. \'on Leube observed 
one case in which the pain along the vertebral 
column was most intense when the patient sat up. 
On lying down the pain disajjpeared completely. 
Vigorous pressure over the spinal muscles also 
failed to elicit any discomfort. The chaotic and 
varying pathology of the disease may possibly 
explain the inconstant presence of this subjective 
symptom. 

Acute poliomyelitis. — In the severe types of thi.s 
affection with dural involvement the backache is 
very severe and persistent and assumes the charac- 
teristics of the pains in cerebrospinal meningitis. 
They may be coincident with the on.set of the infec- 
tion or may precede it for a number of days. The 
spinal muscles are held rigidly, all movements, either 
volitional or induced, intensifying the distress. The 
pains persist throughout the acute phase of the dis- 
ease and subside with the onset of the paralytic 
phenomena. This is not constant, however, for in 
a considerable number of cases observed in the 
epidemic of 1916 the spinal rigidity and ])ain per- 
sisted months after the development of the ])aralysis. 
Evidently a subacute pachymeningitis was respon- 
sible for the persistence of the symptoms. The back 
pains, as described by mature patients, are diffuse, 
boring, and tearing, with a subjective sense of 
tremendous weight and pressure. In mikl cases of 
poliomyelitis there is a> a rule no complaint of 
backache. A vague sense of discomfort dift'u>ed 
over the entire back has been observed in the 
moderately severe cases of this disease. 

Herpes zoster. — Severe and persistent pains in 
the back will in a great majority of cases herald 
the advent of this affection. The pain is sharjilv 
localized and is in approximate relation to the in- 
volved posterior root and its ganglion. It is de- 
scribed as gnawing and burning in character. W'nh 
the appearance of the herpetic vesicles, the i)ain> 
assume a radiating character and are definitelv 
marked by the anatomical distribution of the inter- 
costal nerves. It is well to bear in mind the pos- 
sibility of a zoster infection in a sharply localized 
pain with sudden onset limited to the spinal mus- 
culature. A special characteristic of herpes zoster 
pains are their persistence long after the disappear- 
ance of the vesicles. They assume a definite neu- 
ralgic character which may affect the back or sides 
of the thorax or trunk with equal persistencv. 

HEMORRHAGE. 

Hemorrhage aft'ecting the spinal meninges 
( hematorrhac'ii-^ ) is associated with backache of the 
most violent kind. The extrava.sation of blood may 
occur either in the epidural or subdural .--pace. .As 
soon as the bleeding occurs 'he irritative plienomena 
assert themselves almost at once. There is excru- 
ciating pain .sharply localized and in api)roximate 
relation to the site of the hemorrhage. This locali- 



140 



ROSEXHECK: NEUROLOGICAL BACKACHE. 



[New York 
Meo[C.\l Tourxal. 



zalion does not persist, however. As the blood 
gravitates in the dural sac the pains travel down- 
ward and eventually involve all of the spine below 
the point of bleeding. The back muscles become 
very rigid and pressure o^ movement increases the 
distress a great deal. The pains persist with vary- 
ing intensity for a considerable period after the 
hemorrhage has ceased. With the absorption of 
the clot they gradually diminish in severity and 
eventually disappear. It is well to mention here 
that in large hemorrhages — the socalled spinal 
apoplexy — the back pains may at once, assume a 
radiating character, due to pressure on the posterior 
roots. This radiation is a late symptom in the 
majority of cases, and appears usually with the onset 
of the paralytic phase of the affection. 

Hemorrhage into the cord substance ( hemato- 
myelia), if extensive, may produce backache as the 
result of lateral distention of the cord with conse- 
quent pressure on the dural covering and the pos- 
terior roots. The pain is of sudden onset, becomes 
sharply localized, and is in approximate relation to 
the site of the hemorrhage. This back pain, how- 
ever, is of a fleeting character, soon to be followed 
by the onset of the paralysis. In most cases of 
hemorrhage into 'the cord substance the initial pain 
is absent. It is the paralytic phenomena that at 
once present themselves. 

VASCULAR DISTURBANCES. 

Hyperemia of the cord as a cause of backache 
was a common diagnosis and in great favor with 
the clinicians of the past. They evidently attempted 
to give a pathological status to the great and ill 
defined mass of back pains occurring in the various 
neuroses and toxemias. In the light of modern 
pathology the diagnosis of hyperemia of the cord 
belongs more to the realm of fancy than to fact. 
As a cause of backache, therefore, it may be left 
out of consideration. 

Intermittent claudication. — A number of authors, 
notably Dejerine, have described this condition as 
affecting the spinal arteries. On this basis he has 
described a syndrome characterized by severe lumbo- 
sacral pain with transient sensory and motor 
disturbances affecting the lower extremities. An 
analysis of this affection has led him to believe that 
an angiospasm of the blood vessels supplying the 
lumbar enlargement is responsible for the symp- 
tomatology. In a patient with marked evidences of 
arteriosclerosis, I was able to confirm Dejerine's 
observations. The onset was quite sudden with a 
marked sense of weight over the lumbosacral area. 
This lasted for a short time and was quickly fol- 
lowed by paresthesia and marked weakness in both 
lower extremities. There were no pathological 
reflexes present as observed by Dejerine and others. 
The deep reflexes, however, were markedly increased 
and an exhaustible ankle clonus was easily elicited. 
The sensory and motor disturbance disappeared 
completely in twenty-four hours, but a vague sense 
of pressure and discomfort persisted in the lower 
portion of the spine for about ten days. No doubt 
a great number of back pains that suddenly in- 
capacitate the aged are probably due to the tem- 
porary vascular constriction of the spinal arterial 
supply. 



VASCULAR ABNORMALITIES. 

The rare possibility of enlargement of the spinal 
veins in relation to unexplained backache is to be 
borne in mind. Krause, Gaupp, Jumentie, Valensie, 
Lindeman and Elsberg (quoted by Elsberg) have 
described the clinical and surgical aspects of these 
cases. Obviously they have dwelt in the main on 
the broader symptomatology of the gross sensory 
and motor disturbances, which the enlarged veins 
produce. These vascular abnormalities give the 
clinical picture of new growths of the cord with all 
their attendant pressure effects. The character of 
the back pains, therefore, is to be interpreted from 
that viewpoint and merit no special description. 

NEW GROWTHS. 

In a considerable number of tumors of the cord, 
particularly those of the extradural or intradural 
type, backache may be an early subjective complaint. 
The character of the pains can be described as 
boring, burning, or a vague sense of pressure. Its 
localization depends on the site of the tumor mass. 
Thus it may be in the cervical, cervicodorsal, dorso- 
lumbar or lumbosacral region of the spine. The 
localization of the pain does not last very long, 
however. As the neoplastic process spreads and an 
invasion of the posterior root or its ganglion results, 
the pains become diffuse and radiating in character. 
Eventually they are sharply limited to the segments 
involved. The nature of the pains in spinal cord 
tumors (the dural variety) are their severity and 
persistence throughout the course of the disease. 
The onset of paralytic phenomena does not mitigate 
the patient's suft'erings. Relief is obtained only by 
death or operative interference. 

In the intramedullary type of tumor we hardly 
ever encounter the subjective symptom of back 
pains. It may be observed, however, as a late 
symptom long after the development of the paralysis. 
This is to be explained by the invasion of the pos- 
terior roots and meninges, the inevitable result of 
extension of the tumor mass. The characteristics 
of these pains have been dwelt upon under the dural 
types of tumors, and need no further description. 

NEUROSYPHILIS. 

Under neoplastic processes we may well include 
syphilitic affections of the cord and meninges. 
These gummatous exudates readily assume the 
characteristics of tumors with all their pressure 
effects. Thus the localized or diffuse types of 
meningomyelitis may be ushered into clinical being 
by the advent of severe back pains. These pains 
have certain features that merit special description. 
They come on insidiously and may involve the 
entire musculature of the back. At times the pain 
is sharply localized and then again may shift about 
and eventually become diffuse. The distress is in- 
creased by pressure or movement of the spine. 
Rigidity of the muscles is not uncommon, and in 
some cases is quite marked. 

PacJiymeningitis ccrvicalis hypcrtropJiica. — In 
this affection we are also, dealing with a neoplastic 
]>rocess which exerts marked pressure effects on 
the dural covering of the cord. As a result pain 
in the cervical region is a very early symptom. The 
pain is sharply localized and is characterized by its 



January 22, 1921.] 



ROSENHECK: X EURO LOG I CAE BACKACHE. 



141 



severity and persistence. It may be described as 
boring or pressing. Two patients under my care, 
who were carefully interrogated on this point, de- 
scribed the pain as a combination of pressure and 
paresthesia. The muscles in the cervical area may 
be quite rigid and sensitive to pressure. The local- 
ization of the pain lasts a variable period and is 
followed by the usual radiating character of pain, 
indicating involvement of the posterior roots. It 
seems opportune at this point to emphasize the fact 
that the pain in neoplastic processes of the cord and 
meninges is not at all times limited to the back. 
With the increase in growth of the tumor mass and 
inevitable invasion of the ganglia and posterior 
roots, the pains assume a definite radiating char- 
acter. It is quite obvious that this radiating pain 
may be the very first subjective complaint whenever 
pathological processes invade primarily tlie posterior 
roots. 

DEGENERATIVE DISEASES. 

Tabes dorsalis may initiate its chnical appearance 
with a persistent pain in the back. This is not per- 
manent nor characteristic. As we are dealing in 
this aiYection with a primary aadiculitis, the pains 
early assume a distal character. Thus the radiating 
or lightning pain has been recognized as an intimate 
associate of this disease for a great number of years. 
It dominates the clinical picture from its inception 
and definitely stamps the affection. 

Paralysis agitans, combined sclerosis, multiple 
sclerosis, and the various types of secondary tract 
degenerations, may at some time during their onset 
or course of development be the subject of pain in 
the musculature of the back. This discomfort is 
more readily explained by the fixed attitudes which 
the patient has to assume in getting about. The 
mechanical difficulties of locomotion add great bur- 
dens to the spinal muscles which conduce to their 
fatigue and discomfort. As this backache has no 
pathological significance, its furtlier description 
seems unnecessary. 

NEUROSES. 

In traumasthenia and neurasthenia, backache holds 
the centre of the clinical stage. Its essential fea- 
tures have been mentioned under the chapter on 
etiology. The clinical importance of this subjective 
complaint may be considered from the effect that 
it has on the patient's morale and its defiance to 
all accepted methods of treatment. Its economic 
importance claims even greater consideration, for 
we are all familiar with the impaired working 
capacity of the affected individual. 

In considering the backache of traumasthenia we 
find that it follows soon after the primary effect of 
the injury has passed away. The pain may be dif- 
fuse or localized to the lower lumbar area. In the 
majority of cases the lumbar type of pain is mani- 
fest. The distress is constant land increased by all 
physical effort. It is described as a sense of weight 
and pressure, and there are areas of extreme tender- 
ness to pressure. Rest has little if any influence in 
alleviating the pain. It may also assume a lancinat- 
ing character associated with moderate paresthesia. 

The backache of neurasthenia is a backache of 
adjectives, as one author has facetiously named it. 



It holds the patient in a relentless clutch and is 
usually increased by mental or physical effort. It 
may he localized to any portion of the spine, but as 
a rule involves the dorsolumbar mu.scles. Rest may 
mitigate the distress, but not to any appreciable 
degree. As heretofore stated, it is a pain particu- 
larly rich in adjectives, and its embellishment is 
limited only by the literary ability of the sutferer. 
The chief characteristics of this hack ])ain may be 
summed up as follows: Persistent and diffuse char- 
acter of pain ; early fatigue of back muscles after 
])hysical or mental eifort ; marked points of tender- 
ness over muscle .segments, and evident emotional 
instability. 

DIAGNOSIS. 

As backache is only a symptom of a particular 
morbid process, it would be a manifest fatuity to 
speak of the diagnosis of a symptom. Obviously 
when a patient complains solely of back pain the 
most thorough inquiry and examination should be 
instituted, in order to discover the cause of it. 
A perfunctory glance and a bottle of liniment is 
a bit unscientific and rarely brings results. A frank 
neurological affection may he menacing the patient, 
and its diagnosis ' should be established as soon as 
possible, for I have observed irreparable injury to 
the spinal axis in cases where this humble symptom 
was the only complaint. It is obviously hazardous 
to attempt a diagnosis of the underlying condition 
by the peculiarities of each backache. In acute con- 
ditions it may be a very simple matter when other 
associated symptoms are apparent ; but in chronic 
backache, all the descriptive powers of the patient 
will not make the diagnosis for us. It may aid 
considerably in giving this symptom its proper 
evaluation and guide us in arriving at a definite 
conclusion. The practitioner must always bear in 
mind that it is only a symptom of an underlying 
disorder, wliich painstaking examination will reveal 
to him. 

TREATMENT. 

The treatment of backache in neurological dis- 
eases is obviously the treatment of the underlying 
condition producing the disturbance. It is not the 
purpose of this article to dwell at length on the 
methods to be pursued in each given case. They 
will readily suggest themselves to the intelligent 
practitioner as soon as he views his cases in their 
proper perspective. Above all. he should avoid 
treating backache by symptomatic means. In the 
main the treatment will be directed by a combination 
of methods which will take into consideration the 
primary morbid process and the evils that flow 
therefrom. 

370 Central Park West. 



A Comparative Study of the Mechanism of 
Wound Healing. — Leo Loeb {Journal of Medical 
Research, January, 1920) attempts to explain on a 
theoretical basis the various phenomena observed 
during the healing of wounds. It is stated by Loeb 
that the reactions seen in wound healing are to be 
considered es.sentially as reactions of cells toward 
foreign bodies. 



142 



in I. LARD: GYNECOLOGICAI. BACKACHE. 



[New York 
Medical Journal. 



i GYNECOLOGICAL BACKACHE.* 

By E. a. Bui.l.\rd, M.D.. F.A.C.S., 
New York, 

Assistant Surgeon, Woman's Hospital 

A small volume might be written about backache 
if this symptom was studied exhaustively from every 
viewpoint, and a most interesting and instructive 
treatise it would be. I'robably the longest chapter 
should be written by the orthopedist, but the gyne- 
cologist, neurologist and internist could contribute 
much interesting material, and so interdependent 
should these be that the authors would do well to 
consult each other freely in the preparation of their 
respective monographs. 

Some surprising observations made in the post- 
operative followup clinic at the Woman's Hospital 
during the past few years led me to feel that an 
;uialytical study of backache would be interesting. 

There is a justifiable scepticism of statistics. 
Contentions of every sort have been backed up by 
statistics at one time or another, but I am not trying 
to prove anything. I wish merely to lay before you 
what the records show. While there is of course a 
certain percentage of error in these reports. I be- 
lic^"e that the rather thorough methods now in 
operation at the W^oman's HosjMtal produce ap- 
proximately accurate figures of the work. Seven 
hundred and twenty-one cases of backache, with 
sufficient data for satisfactory study, were taken up 
in order from the records of the followup clinic 
since 1915 and tabulated for this analysis. 

GROUP I. 

Retroversion uncomplicated by any other 

gynecological abnormality 129 Cases 

Backache cured by operation 10,^ Cases 

Gilliam operation 34 

Bissell operation 10 

Simpson operation 14 

Internal Alexander 13 

Grad U 

Miscellaneous operations . . 13 
Backache unrelieved by operation 26 Cases 

Simpson operation 4 

Gilliam operation 4 

Bissell operation A 

Ventral suspension 2 

Round ligament ])lication. 8 

Miscellaneous 4 

These latter cases were anatomically successful 
and nothing remained to explain the failure. 

This, then, is a series in which the backache might 
reasonably have been ascribed to the displaced 
uterus, but end results virtually proved that twenty 
per cent, of these backaches were not from that 
cause, and were almost certainly not gynecological. 

GROUP II. 

Retroversion with adnexal inflammation . 68 Cases 

Backache cured by operation 59 Cases 

Backache imrelieved by operation 9 Cases 

.Xnatomically .satisfactorj- retroversion operations 

'Read at the November meetin? of the New York Obstetrical 
'•ociety, 1919; also before the Buffalo .Xcademv of Medicine, Mav 
19, 1920. 



with salpingectomy were performed, and no tender- 
ness or induration remained to account for the con- 
tinuation of the pain. 

Here we found elimination of the pressure of an 
adherent uterus or a tuboovarian mass, or relieving 
the drag of adhesions seemed to cure eighty-seven 
])er cent, of the backaches, leaving thirteen per cent, 
jjrobably not pelvic, but not diagnosed. 

GROUP III. 

Adnexal inflammation only 19 Cases 

The results here seem to justify the opinion that 
salpingitis with adhesions produces backache, for 
all but two of this group were cured by ablation of 
inflamed tubes — and sometimes the ovaries — and the 
release of adhesions. About ninety per cent, were 
cured. 

GROUP IV. 

Lterine prolapse (of various degrees).. 84 Cases 

Backache cured by operation 75 Cases 

Various ligament operations for first de- 
gree prolapse 23 

\\'atkins operation 20 

Mayo operation 14 

Bissell trisection uterus 3 

Abdominal hysterectomy 3 

A aginal hysterectomy with Bissell cysto- 

cele operation 3 

Miscellaneous operations 9 

Backache unrelieved by operation 9 Cases 

Goffe operation 2 

Baldwin operation 1 

Watkins operation 1 

Bissell trisection uterus. . . 1 

!Mayo operation 1 

\'aginal plastic operations 
with round ligament 

ojjeration 3 

Operation was anatomically satisfactory and no 
pelvic lesions found to explain continued pain. 

In tliis important series we found eighty-nine per 
cent, of the cases relieved by operation, the back- 
aches probably having been due to the drag on pelvic 
supports and therefore cured by successful ana- 
tomical repairs. 

GROUP v. 

Plastic oi>erati"n-> ou'v 4^^ Ca-^es 

Uncomplicated rectocele 9 Cases 

Cures 5 

Failures in spite of success- 
ful plastic operation. ... 4 
Cystocele and rectocele ( without pro- 
lapse ) 12 Cases 

Backache cured 6 

Backache unrelieved de- 
spite satisfactory anatom- 
ical repairs 6 

Repairs of cervix and perineum 17 Cases 

Backache cured 1 

Backache unrelieved though 
the plastic operations 

were well done 2 

Cervix operations 8 Cases 

These operations were j^erformed for cystic, 
eroded, lacerated, hypertrophied cen'ix or chronic 



January 22, 1921.] 



RULLARD: GYNECOLOGICAL HACKAi llli. 



14.^ 



endocervicitis, and the l)ackachc was cured in every 
case. 

This group of plastic cases is too small from 
which to draw conclusions, but I present the figures. 

GROUP VI. 

Uncomplicated retroversion with lacera- 
tions of perineum or cervix ( iiack- 
ache cured in every case) 23 Cases 

Gilliam operation and 
perineorrhaphy 12 

Round ligament operation 
of one or another type 
with repair of cervix and 
pelvic floor 11 

GROUP VII. 

Uncomplicated ovarian cyst 7 Cases 

Backache cured by opera- 
tion 5 

Backache unrelieved hy 
operation 2 

GROUP VIII. 

Fibromyomata uteri ScS Cases 

Without adnexal inflammation, adhe- 
sions, or other complication. 
Backache cured by hyster- 
ectomy 33 

Backache unrelieved by 
hysterectomy 5 

GROUP IX. 

Complex conditions ^07 Cases 

This title is used for lack of a better one. The 
cases all presented a combination of lesions. The 
classification is most unscientific, but in every case 
there were two or more conditions present, each of 
which was capable of producing a backache. Ob- 
viously, conclusions drawn from the study of such 
a series would be of doubtful value. An example 
of the type of patient put into this class would be 
such as this : A repair of cervix, cystocele, and 
pelvic floor, combined with a retroversion operation 
and adnexal work. To detemiine the cause or cure 
of such a woman's backache would be a hard prob- 
lem. Usually, that is, in eighty-five per cent, of 
these patients, the backache was gynecological, for 
the operative procedures were successful in its relief. 
Backache cured by operations. . .260 Cases 
Backache unrelieved by opera- 
tions 47 Cases 

Though you have been deluged by figures and 
percentages, one fact has surely been apparent all 
through this analysis, namely, that there were a 
number of cases in every group in which ojierative 
results were anatomically excellent, and no gyneco- 
logical abnormality remained to account for the un- 
relieved backache. To summarize : 

Twenty per cent, of the uncomplicated retro- 
version cases. 

Fourteen per cent, of the uncomplicated fibroids. 

Thirteen per cent, of the retroversions with ad- 
nexal inflammation. 

Ten per cent, of the adnexal inflammations. 

Ten per cent, of the prolapse cases. 

Fifteen per cent, of the large complex group. 



Obviously, at least fifteen per cent, of the cases 
of backache that we see in tlie Woman's Hospital 
are not gynecological. 

Since the early days of my work in outpatient 
gynecological clinics 1 had been impressed by the 
frequency of the symptom backache. Stimulated 
by the writings of l>radford and Lovett, Dickinson 
and Truslow, and others, 1 became more interested 
in this symptom and acquired the habit of referring 
many ]>atients with obscure backache to clinics in 
internal medicine, orthopedics and neurology for 
further investigation. Most often it was the ortho- 
pedist who cleared up the diagnosis and the fre- 
quency of such conditions as sacroiliac joint trouble, 
lumbar myositis, arthritis of lumbar spine, disturbed 
muscle balance, flat feet, spinal curvatures, faulty 
attitude, etc., was interesting and instructive. 

Dr. George Gray Ward, jr., chief surgeon of the 
Woman's Hospital, holds a similar opinion concern- 
ing the frequency with which gynecological and 
orthopedic causes coexist in the i)roduction of back- 
ache in females, and has established an ortho])edic 
gynecological clinic at that hospital largely for 
diagnosis. 

As I meditated on my series of cases it occurred 
to me that it might also be of considerable interest 
to gather u]) and classify those cases in whicli the 
more common gynecological causes of backache were 
present, but which I had discarded as I went along 
because none of the patients had ever had a back- 
ache. 

SERIES I. 

Adherent retroversion with inflamed 



adnexa 47 Cases 

SERIES II. 

Uncomplicated mobile retroversion 20 Case- 

SERIES III. 

Prolapse of various degrees 20 Case-^ 

SERIES IV. 

Procidentia 9 Cases 

SERIES V. 

Complex cases (with .several gynecological 
conditions in each case capable of 
producing backache ) 29 Case- 
Total 125 Case. 

CONCLUSIONS. 

1. In a series of 721 cases of backache studied at 



the Woman's Hospital, eighty-five per cent, were 
cured by an appropriate operation. 

2. About fifteen per cent, of this series presenting 
one or more common gynecological causes of back- 
ache were not relieved of the backache by anatomic- 
ally satisfactory operations. 

3. Probably much more than fifteen per cent, of 
the backache in females is not gynecological. 

4. My series suggests that fifteen or twenty per 
cent, of all women with retroversion, prolapse, pel- 
vic inflammations, ob.stetrical lacerations, or pelvic 
tumors, do not have backache. 

5. Closer cooperation with the orthopedist, the 
internist and the neurologist should enable us gyne- 
cologists better to diagno-^e and treat backache in 
women. 

47 E.vsT Fifty-seventh Street. 



144 



SOLIS-COHEN: LATEST PULMOXARY TUBERCULOSIS. 



[New 
Medic.vl 



York 
Journal. 



LATENT PULMONARY TUBERCULOSIS 
IN ITS VARIOUS DISGUISES. 

By Myer Solis-Cohen, A.B., M.D., 
Philadelphia. 

Pulmonary tuberculosis one naturally associates 
with symptoms referable to the lungs. Its occur- 
rence without cough and expectoration is not gen- 
erally recognized, nor indeed much referred to in 
lectures, medical articles, and textbooks. When 
these symptoms are lacking, therefore, the pul- 
monary condition frequently fails of diagnosis, 
especially if the physician does not make a practice 
of examining the lungs of all his patients, no matter 
what their complaints. 

I use the term latent pulmonary tuberculosis for 
those cases of tuberculosis of the lungs in which 
there is no cough. The symptoms the patients com- 
plain of are many and varied, but may be divided 
roughly into several groups, namely, nervous, auto- 
nomic, gastrointestinal, asthenic, rheumatic, derma- 
tological, cardiac, menstrual, and general. As might 
be expected, patients without cough seldom find 
their way into sanatoria, and thus are not so well 
known to the sanatorium physicians, from whom 
much of our knowledge in regard to tuberculosis 
naturally comes. I have never seen a latent case 
in either of the sanatoria with which I have been 
connected, the cases I am reporting being found in 
the course of my private practice. In fact, it is the 
general practitioner, the neurologist, the gastro- 
enterologist, the internist who sees these cases, and 
in many instances unfortunately fails to detect their 
tuberculous nature. The tuberculosis specialist, as 
a rule, meets with them only when he examines the 
presumably healthy members of the family of a 
tuberculous patient ; for seldom does a patient with- 
out cough visit the office or dispensary of one who 
treats only tuberculosis. That many other symp- 
toms in addition to cough, expectoration, hemo- 
ptysis, fever, and night sweats may occur in patients 
suffering from pulmonary tuberculosis is a matter 
of common knowledge, although sufficient attention 
or emphasis has not been given to them. But that 
these phenomena may be present in pulmonary 
tuberculosis while symptoms referable to the lungs 
are absent, is less generally known. Consequently 
tlie admonition to physicians to examine carefully 
the chest of all patients with cough, and the warn- 
ing to the laity about neglecting the chronic cough, 
are of no avail in discovering these latent cases. 
Nor will but a fraction of such unrecognized cases 
be found among the public health morbidity records, 
which consequently may often be misleading. 

In the absence, therefore, of much definite data 
in regard to this condition, which I believe to be 
f|uite widespread, I have attempted an analysis of 
seventy-five of my patients exhibiting pulmonary 
consolidation without suffering from cough. It 
must be remembered that the symptoms noted in 
cacli case are merely those of which the patient 
complained. There has been no attempt at a 
thorough investigation of each patient as to the 
j)rcs('nce or absence of the various symptoms, with 
llic exception of autonomic phenomena in a number 
of the cases. Had they been systematically in- 



quired for, no doubt various nervous, gastric, 
general, or other symptoms might have been elicited 
from patients who did not think to mention them. 
The number of patients reported as complaining of 
a certain symptom, therefore, merely serves as an 
index to the frequency that symptom is complained 
of, but must not be computed in an accurate or 
even approximate percentage. 

For convenience I have grouped the symptoms 
under seven heads : Nervous symptoms, autonomic 
phenomena, gastrointestinal disturbances, pains, 
menstrual and other pelvic disorders, skin eruptions, 
and general or systemic symptoms, the last includ- 
ing asthenic, cardiac, and other symptoms. 

Sex, age, and social condition. — Of the seventy- 
five patients included in this analysis twenty-four 
are males and fifty-one females. Four were ten 
years of age or younger, thirteen between eleven 
and twenty, twenty-nine between the ages of twenty- 
one and thirty, sixteen between thirty-one and fifty, 
seven between forty-one and fifty, and one in each 
of the next two decades. The age was not recorded 
in the rest. Forty-two were single. Five were 
widowed or divorced, two of whom had remarried 
and the second consort was living. The rest were 
married, the consort being ahve. 

Classification. — One was in the far advanced 
stage (according to the classification of the National 
Tuberculosis Association) ; the rest were socalled 
incipient or first stage cases. Three were in Tur- 
ban's class two, one in his class three, and the rest 
in his class one. 

Family history. — Thirty-two gave a family his- 
tory of tuberculosis, seven a history of a long stand- 
ing cough in a parent, six a history of tuberculosis 
in the consort, and nine a history of tuberculosis 
in the children. Twenty-six gave a family history of 
autonomic disturbance, eleven a neurotic family his- 
tory, seven a family history of enlarged thyroid 
gland, and seven a history of alcoholism in a parent. 

Factors associated with the onset of sxinptoiiis. — 
The chief symptoms from which the patients com- 
plained dated from an operation in five, from men- 
tal strain or grief in four, from coming to a city 
in four, from an illness in four, from an accident 
in two, from marriage in one, and from a confine- 
ment in two. The)' became worse after mental 
worries in seven, after an accident in three, after 
marriage in two. and after pregnancy in two. 

Distribution of symptom groups. — Sixt3'-three 
of the patients complained of nervous symptoms, 
fifty-two of pains, fifty-one of autonomic phe- 
nomena, thirty-five of gastrointestinal disturbances, 
twenty-eight of menstrual disorders, sixteen of skin 
eruptions, and sixty-seven of asthenic, cardiac, gen- 
eral, and other symptoms. Three of the patients 
complained of symptoms in all of the seven groups, 
nine of symptoms in six of the groups, twenty of 
symptoms in five, seventeen of symptoms in four, 
fourteen of symptoms in three, seven of symptoms 
in two, and three of symptoms in but one of the 
groups. Each symptom under the group headings 
is followed by the number of patients in whom it 
wa's noted. 

A'crz'ous symptoms. — The chief nervous symp- 
toms complained of were: Nervousness, fifty-six; 



Januarv 22, 1921.] SO LI S -C O HEN : LATENT PULMONARY TUBERCULOSIS. 



145 



depression, twenty- four ; insomnia, twenty -one ; 
irritability, twenty-tliree ; excitability, sixteen ; rest- 
lessness, twelve ; being fidgetty, eight ; tremors, nine ; 
hysteria, six ; twitching, six ; nervous prostration, 
seven ; disagreeableness, five ; mental tire, five ; 
hysteria, five, and nausea or vomiting accompany- 
ing headache, six. 

Less frequent were the following: Feeling of 
impending danger, three; sexual hyperesthesia, 
three; masturbation, three; phobia, three; bad be- 
havior, three, and mental confusion, three. Occa- 
sional symptoms were, gaping, two; nightmare, 
two; aphonia (hysterical), two; globus hystericus, 
two ; diarrhea when nervous, two ; epilepsy, two ; 
self consciousness, two ; and dreams, loss of memory, 
stupidity, chorea, abdominal pain during electrical 
storm, somnambuHsm, stiffness in legs, "picking" in 
arms, itching of legs, melancholia, sighing, and 
\ omiting when excited, each one. 

Pains. — Of the pains complained of the most 
frequent were : Headache, thirty-one ; backache, 
nineteen ; pain in the legs, fifteen ; in the precordium, 
twelve; in the chest, twelve; in the back of the 
neck, eleven ; in the abdomen, eleven ; in the sacro- 
iliac joint, eleven ; in the shoulder blade, five ; in 
the supraorbital region, five ; in the arm or arms, 
five ; and in the shoulder, five. Less frequently they 
were in the knee, four ; sternum, four ; thigh, three ; 
breast, three ; hand, three ; between the shoulders, 
three ; in the ankles, three ; and in the finger, three. 
Occasionally they were in the side of the face, two : 
elbow or elbows, two ; ear, two ; hip, two ; eyes, two ; 
below the clavicle, one ; in the scalp, one ; lips, one ; 
back of the chest, one ; jaw, one ; pelvic region, one : 
epigastrium, one ; feet, one ; thyroid gland, one ; and 
all over, one. Several patients complained of back- 
ache associated with nervousness, one of pain in the 
finger tips and nails when nervous. In several 
(four) the pain was worse on excitement and worry 
and in one case it was brought on by them. Three 
patients complained of pain on urination, one of 
pain in the end of the penis, and one of pain on 
coitus. Six patients complained of what they 
called neuralgia, one of rheumatism, and one of 
stiffness in the neck. 

A:itcr.c:^.'.ic f'I'.cv.cir.cr'.::. — The autonomic phe- 
nomena were studied more thoroughly than any 
other group of symptoms, because for the past 
fifteen years or more I have been impressed with 
the frequency of the phenomena of autonomic 
ataxia in tuberculous subjects. Those most fre- 
quently met with were dermographia, forty-four ; 
pallor, forty-two ; tricolored finger nails, thirt}-- 
seven ; sweating, exclusive of night sw-eats, thirty ; 
flushing, thirty ; showing of sclera above or below 
the cornea on opening the eyes widely, twenty-four ; 
subjective sensation of cold, twenty-three ; migraine, 
twenty-two ; raising of the eyebrows on opening 
the eyes widely, eighteen ; bleedings, exclusive of 
hemoptysis, eighteen ; urticaria, seventeen ; the leav- 
ing of a black line when a silver probe is drawn 
across the face, fifteen ; showing of sclera normally 
above or below the cornea, seventeen ; feeling worse 
in hot weather and better in cold weather, fourteen ; 
nosebleed, eleven ; angioneurotic edema, nine ; show- 
ing of sclera above or below the cornea on raising 



the eyebrows, nine ; tendency to bleed easily, eight ; 
numbness, eight ; general burning, seven ; subjective 
sensation of heat, seven ; enervated by heat, six ; 
worse in the winter — inability to stand the winter 
well or to stand cold water, six; rigor, six; pros- 
trated by heat, six ; low blood pressure, five, and 
hoarseness without a "cold," five. 

Less frequently were noted tingling, four ; uni- 
lateral burning, four; vomiting accompanying pain, 
four ; nausea accompanying pain, three ; asthma, 
three ; hay fever, three ; sweating with weakness, 
three ; food anaphylaxis, three ; and, occasionally, 
inability to stand constriction about the neck, two; 
showing of sclera above or below the cornea on 
fixing the eyes, three ; weak voice, two ; closing of 
the throat, one ; dryness of the lips, one ; throbbing 
of the head, one; sunstroke, one; hot flashes, one; 
eyes hot, one ; feeling of cold water running over 
the body, one ; nausea with weakness, one ; nausea 
with insomnia, one ; tight feeling in the head, one ; 
desire for sweet things preceding migraine, one; 
great desire for food preceding migraine, one ; 
diarrhea when tired, one ; bearing extremes of 
weather badly, one ; swelling of fingers when excited 
or washing clothes, one; cyanosis, one; and idio- 
syncrasy to quinine, one. 

The thyroid gland could not be felt in twelve 
cases, was merely palpable in fifteen, and was 
slightly enlarged in eight, moderately enlarged in 
fourteen, and markedly enlarged in four. 

Gastrointestinal symptoms. — The chief gastro- 
intestinal symptoms complained of were nausea, 
nineteen; eructation, sixteen; vomiting, eleven; 
epigastric pressure, smothering, lump, weight or 
heaviness, eleven ; epigastric pain, ten, occurring im- 
mediately after eating in one case, and one hour 
after, two hours after, and with no relation to 
eating in three cases each ; pyrosis, nine ; abdominal 
pain, nine ; sour taste, eight ; appendicitis-, six ; so- 
called nervous dyspepsia or nervous indigestion, six ; 
heartburn, six; and distention, five, Less fre- 
quently were noted bitter taste, three ; epigastric 
tenderness, three ; pylorospasm, three ; gastrointes- 
tinal attacks, three ; hemorrhoids, three ; blood passed 
by bowel, three ; diarrhea, three ; and, occasionally, 
salivation, two ; cardiospasm, two ; rectal prolapse, 
two ; gastric distress, one ; hyperacidity, one ; ab- 
dominal pain after eating, one ; abdominal pain 
when the stomach is empty, one ; "boiling" of the 
stomach, one ; disturbance from gas, one, and mucous 
colitis, one. 

Pelvic symptoms. — The most common of the 
menstrual and pelvic disorders were dysmenorrhea, 
sixteen ; exacerbation of other symptoms during the 
menstrual period, ten ; irregular menstruation, ten, 
and menorrhagia, nine. Less common were metror- 
rhagia, three ; increase of headache at the menstrual 
period, three ; and, occasionally, pain or heaviness 
in the breast during menstruation, two ; frequent 
menstruation, two ; exacerbation of symptoms dur- 
ing pregnancy, one ; during confinement, one, and 
(luring lactation, one; subjective sensation of cold 
immediately preceding menstruation, one; backache 
at the menstrual period, one ; hemoptysis during 
pregnancy, one, and at the menstrual period, one; 
nosebleed at the menstrual period, one ; scanty men- 



146 



SOIJS-COHEX: LATENT PULMONARY TUBERCULOSIS. 



[New York 
-Medical Journal. 



stniation, one, and enlargement at the menstrual 
period of a btirsa on the wrist, one. 

General symptoms. — Of the symptoms classed as 
general those most frequently complained of were 
weakness, forty-three ; tendency to tire easily, thirty- 
eight ; being always tired, twenty-eight ; malaise, 
twenty-five ; dyspnea on exertion, twenty-six ; ver- 
tigo, twenty-six ; palpitation on exertion, twenty ; 
anorexia, nineteen ; loss of weight, nineteen ; failure 
to gain weight prior to treatment, eighteen ; failure 
to gain weight after treatment, sixteen ; dyspnea, 
sixteen ; listlessness, languor, lack of ambition, fif- 
teen ; constipation, fifteen; exhaustion, fourteen; 
palpitation, fourteen ; sore throat or dysphagia, 
eleven ; hemoptysis, nine ; lessened appetite, nine ; 
furunculosis, eight ; fainting, seven ; f reqtient urina- 
tion, seven, and increased pulse after exercise, five. 

Less frequent were drowsiness, four; acne, four; 
sacroiliac strain, four ; xiphosternal crunching sound, 
four ; circles under the eyes, three ; carbuncles, 
three, and tenesmus or burning on urination, three. 
Occasionally were noted eczema, two ; falling of 
the hair, two ; inclination of the head to one side, 
two; maculopapular eruption, two; emaciation, two; 
precordial fluttering, one; miliaria, one; erysipelas, 
one; inability to void urine, one; sexual weakness, 
one ; emissions, one ; nephroptosis, one ; leucorrhea 
when exhausted, one ; abscesses, one, and a feeling 
of a weight on the chest, one. 

The pulse and temperature were not recorded in 
every case. The pulse was 70 or below in one 
case, between 71 and 80 in eighteen cases, between 
81 and 90 in eighteen cases, between 91 and 100 in 
seventeen cases, between 101 and 110 in eleven 
cases, between 111 and 120 in three cases, and 
between 121 and 130 in one case. There was no 
fever in nineteen cases, a fever of 99.5° or less in 
fifteen cases, between 99.6° and 100° in four cases, 
and between 101° and 102° in one case. 

The hemoglobin was between ninety-one and one 
hundred per cent, in one case, between eighty-one 
and ninety in three cases, between seventy-one and 
eighty in two cases, between sixty-one and seventy 
in three cases, between fifty-one and sixty in four 
cases, and between forty-one and fifty in two cases. 

Effect of treatment. — As a rule the symptoms 
described do not subside on symptomatic or ordi- 
nary treatment. Salicylates, aspirin, novaspirin. 
atophan. and oil of gaultheria frequently have no 
efifect on the pains. Bromides control but a small 
proportion of the nervous symptoms, and valerian 
fails in about half the cases. Stomachics, as a rule, 
ar^ of little benefit for the gastrointestinal symp- 
toms. Hexamethylenamine does not relieve the 
urinary symptoms. Iron, arsenic, the glycerophos- 
phates, calcium, digitalis, strychnine, sparteine, pic- 
rotoxine. atropine, and belladonna are of apparent 
benefit in about half the cases where they seem to be 
indicated. Tuberculin is seldom of value. Iodine, 
given by me usually as iodoform, seems to be helpful 
in a little f)ver half the cases where it has been used. 
Preparations of the endocrine glands proved disap- 
pointing. Thyroid gland was beneficial in five out 
of seventeen cases, tliymus gland in one out of five 
cases, pituitary gland in one out of four cases, and 
parathyroid gland and corpus luteum in none. 



Proper hygiene, fresh air, good food, sufficient 
rest, proper exercise, hydrotherapy, and Bier's 
hyperemia of the lungs and bone marrow are always 
indicated, but alone seldom suffice to produce a 
cure. Some few cases seem to retain their symp- 
toms in spite of every method of treatment. C3n 
the whole the therapeutic agents that seemed to 
be of most benefit were iodoform (C. P.), in doses 
of one eighth grain, increased gradually to a grain ; 
iron, arsenic, strychnine, picrotoxine, digitalis, 
valerian, and calcium in the form of the glycero- 
phosphate or the lactophosphate. 

Discussion. — My desire is merely to record the 
various symptoms and phenomena that may be ob- 
served in latent pulmonary tuberculosis rather than 
to explain them. Many, doubtless, have no connec- 
tion with the tuberculous process. It is possible 
that some may be produced as a direct result of 
the body's fight against the tubercle bacillus and 
its toxins. This is probably true of many of the 
symptoms that occur so frequently. I entertain the 
same view in regard to these as I expressed several 
years ago when disctissing the signs and symptoms 
of autonomic disturbance occurring in all forms of 
pulmonary tuberculosis — latent, arrested, improv- 
ing, .stationary, and advancing: "Aly feeling is that 
they are due to an excess in the system of one or 
more of the internal secretions, due to the stimula- 
tion of the thyroid gland and other endocrine glands 
by the tuberculous poison, and are evidences of a 
defense reaction. In latent . . . cases it is possible 
that the endocrine glands, which were stimulated to 
hypersecretion (and possibly hypertrophy) by the 
tuberculous toxin, still continue to secrete in excess 
of the normal after the disease has been checked, 
this excessive secretion giving rise to the various 
phenomena . . ." ( 1 ) . 

This view is in direct ojiposition to that held 
by Sajous, who believes that ttiberculosis is 
preceded by a weakening of the participation 
of the endocrine glands in sustaining the meta- 
bolism of all tissue cells and also their atitodefensive 
activity, which renders the body vulnerable to 
infection. To me the existence of latent pulmonary 
tuberculosis stiggests lessened vulnerability — tuber- 
culous infection with good resistance. For, were 
the symptoms described in this paper indicative of 
vulnerability, we would be likely to have active 
rather than latent tuberculosis. But before any 
theory can be formulated, much more extended 
studies of the ttiberculous process will be required, 
including the participation of the endocrine glands 
in the body's reaction and the effect of their altered 
secretion upon organs and tissues other than the 
lungs. Meanwhile the observant clinician may be 
able to contribute some aid by directing attention 
to symptoms and phenomena that are usually ignored. 
We shall be better able to detect pulmonary tuber- 
ctilosis when it exists without cough and to differ- 
entiate it from conditions that it simulates, the more 
familiar we become with the variotis disguises it 
sometimes assumes. 

REFEREXCE. 

1. SoLis-CoHEX, MvER : American Rd'icw of Tubercii- 
lo.sh. 1917, 1, 289. 

2113 Chestnut Street. 



January 22, 1921.] MELMAX: TABES MESENTERICA. 147 



TABES MESENTERICA FOLLOWING 
INFLUENZA* 

By Ralph }. Melman, M. D., 
Philadelphia, 

Lecture in Pediatrics in the Medical Department of Teniiilc Uni- 
versity, and Assistant Pediatrist to the Samaritan .nnd 
(^arretson Hospitals. 

We have been trained to think that tuberculosi.s 
as a sequel to influenza is generally pulmonary in 
type, and, therefore, we are likely to overlook this 
condition if it involves any other part of the human 
anatomy. Especially should we be careful if this 
occurs in children, as the following case will demon- 
strate. 

Case. — Boy, L. C, aged seven years. His per- 
sonal history showed little of importance during 
his infancy, except a few attacks of dififused bron- 
chitis, due to nasal obstruction, which had been 
corrected by the removal of adenoids at the age of 
fifteen months. At the age of three he liad had 
measles ; no other childhood disease. 

Family history. — Father and mother living, and 
well ; two sisters living. The older sister, aged 
nine, was convalescing from influenza of eight days' 
duration when I was called in to see this boy. 

Present history. — The patient had been perfectly 
well until January 20, 1920, when a rise of tem- 
perature and vomiting occurred. On examination 
I found the temperature 105°, and the child com- 
plained of severe headache and general muscular 
pain. Physical examination revealed a well developed 
boy, weighing about sixty pounds. Nothing was 
noticed on the neck or head, except a few pal])able 
cervical glands. The skin was hot and dry. The 
eyes were injected and there was slight photophobia, 
but they reacted normally to light and accommoda- 
tion. The teeth were in good condition, the tongue 
was coated and the pharynx congested : chest was 
well developed with equal expansion on both sides ; 
respiration 28. A few scattered rales were present. 
There was no organic heart disease; pulse 110. The 
abdomen was symmetrical in outline, with no rigid- 
ity or tenderness. 

Considering the symptoms, physical findings and 
a history of contagion, a diagnosis of influenza was 
made and the patient treated accordingly. This 
condition lasted for three days, when the boy began 
to improve and the temperature, headache, and 
muscular pain subsided and continued so for four 
days, when suddenly, on January 27th, the patient 
complained bitterly of pain in the left side, just 
above the costal margin, increased with respiration.. 
With it there was again a rise in temperature to 
104°, and also slight tenderness over the splenic 
area, which showed slight enlargement. There was 
also an enlargement of the liver. 

Pleuropneumonia or the possibility of enteric 
fever was considered at this stage. We eliminated 
the former by the absence of any of the physical 
signs generally present in this condition. As for the 
latter, we excluded it because of the negative Widal 
test and the presence of a leucocytosis, 17,000, also 
by the absence of any gastrointestinal disturbance. 

On February 3rd there was no change. The 

*Read l);fore the Medical League, December 6, 1920. 



general condition of the patient was fairly good; 
ap])etite good. He slept well, the bowels were 
fairly regular, and he was generally comfortalile. 
The temperature ranged between 104" and 105°, 
being at its highest between eleven a. m. and three 
p. m., when it would gradually subside. The phys- 
ical findings at this stage revealed little of impor- 
tance in the chest. In the abdomen, the enlargement 
of the liver and sjjleen became more prominent. It 
was thought advisable to have the child's chest and 
abdomen x rayed. This was done I5y Dr. Mulford 
K. Fisher, and he reported as follows: "Xo abnor- 
malities found in chest wall. In the abdomen there 
was found an enlarged spleen, and markedly en- 
larged liver." This only confirmed physical find- 
ings. From a further laboratory study we obtained 
the following results: Red blood count. o,800,000: 
white blood count. 6,000; ditferential normal, W idal 
negative, no parasites, Wasscrmann negative, feces 
negative; urine examination showed a trace of albu- 
men, no casts, diazo negative ; spinal fluid negative ; 
von Pirquet markedly positive — so much so that 
the reaction appeared as though it were a vaccinia ; 
blood culture, negative. 

Tuberculosis was suspected, but where? Our 
attention was directed to the abdomen, because of 
a slight persistent distention, uninfluenced by treat- 
ment, and of the enlargement of liver and spleen. 
The nurse was then instructed to measure the 
abdominal circumference daily, with the result that 
in three days there was an increase of an inch and 
a half. 

On February 10th it was observed that the chikl 
was beginning to lose weight, liad slight night 
sweats, the abdomen was noticeably distended, the 
inguinal glands were palpable and tender. At this 
time Dr. H. Brooker Mills and myself could palpate 
some enlarged mesenteric glands. In the few days 
that followed the child's abdomen became extremely 
distended, causing him great discomfort, and he 
complained bitterly of this condition. Active treat- 
ment would only give relief for a brief jjeriod. 
A diagnosis of tabes mesenterica was made, and a 
few prominent surgeons were called in consultation. 
They advised watchful waiting until physical signs 
of fluid in abdominal cavity would develop, when 
surgical interference would be indicated ; meanwhile 
instituting the usual treatment for tuberculosis. 
The child's condition became alarming, in spite of 
forced feeding; the loss of weight was alarming, 
the heart becoming more feeble, the child suffering 
greatly, due to the tympanites. We decided u])on 
operation immediately, which was performed under 
spinal anesthesia. The surgeon's rei)ort was as 
follows: "Mesentery covered with enlarged glands, 
tuberculous in character, some on the verge of 
breaking down, a small amount of fluid in abdominal 
cavity, an enlarged spleen and markedly enlarged 
liver, possibly due to fatty degeneration." 

The child made an uneventful recovery, the tem- 
perature dropping to normal on the sixth day after 
operation and remained so. He has since regained 
his normal weight, and is attending school at present. 

In summarizing, I wish to emphasize a few 
points which I consider important- 



148 



BARNES: HETERO/'HORIA AXD STRABISMUS IN NEURASTHENIA. [New York 

Medical Journal. 



1. Severe pleuritic pain on the eighth day of the 
disease, which I think was referred from abdominal 
cavity, possibly due to the fact that this complication 
commenced in that part of the peritoneum, in prox- 
imity of diaphragm. I have since seen a case of 
tabes mesenterica, where the patient was operated 
on for appendicitis, because pain was referred to 
lower abdomen, with fatal results. 

2. The peculiar temperature curve, being at its 
highest between eleven a. m. and three p. m. 

3. The importance of the von Pirquet test in con- 
junction with other phenomena in puzzling cases, 
in children. 

4. The importance of early surgical intervention 
in this disease, and not resort to watchful waiting 
until the glands break down and have tuberculous 
meningitis as a possible complication, which was the 
tennination of the second case mentioned above. 

5. It is interesting to note that in a proportion of 
cases of socalled potbelly, due to rickets, where 
distention persists, we may have as a complication 
a chronic tabes mesenterica. This is at present 
under investigation at the Samaritan Hospital, and 
we may have a preliminary report on it in the near 
future. 

933 North Sixth Street. 



TRANSIENT HETEROPHORIA AND STRA- 
BISMUS IN NEURASTHENICS. 
By George Edward Barnes, B. A., M. D., 

Herkimer, N. Y. 

I wish to call the attention of the profession, 
particularly of ophthalmologists, to an observation 
which I have made a few times on this subject. 
It is fairly well known that neurasthenic patients 
often have an irregular activity of the ciliary 
muscles. So far as I am aware, however, i^ has not 
been observed that they may also have an irregular 
activity of the extrinsic muscles. I have found that 
these patients, at least in rare instances, show a con- 
dition which is beheved by the ophthalmologists who 
examine them to be an ordinary strabismus or 
heterophoria. If one is familiar with neurasthenics, 
it is not difficult to explain these transient devia- 
tions, for they are merely instances of the irregular 
manner in which some of these neurasthenic patients 
innervate and energize the various muscles of their 
bodies. These irregularities can be easily observed 
in their walk and in the use of their arms. Instead 
of sending the correct amount of nervous force into 
the various muscles concerned in a given act and 
thus producing a normal coordinated action, these 
patients send into certain muscles an unduly large 
amount of nervous force, and jerky, incoordinated 
actions result. Acts which are ordinarily performed 
automatically are made more or less consciously, 
the will sending out into the various muscles a badly 
proportioned set of impulses. 

Of course prisms in the spectacles of these patients 
having temporary muscular deviation are very objec- 
tionable, and operations on their muscles are more 
objectionable. But how is the ophthalmologist to 
distinguish these cases from the usual forms of 



muscular imbalance? I am not quite positive just 
how this can best be done, but here are a few good 
suggestions. The ophthalmologist should be familiar 
with neurasthenic conditions so very prevalent about 
him, and he should know the nature of neurasthenia 
(1 to 4), and not attribute such a thing to that hoax 
and humbug and superstition, socalled intestinal 
autointoxication. When the ophthalmologist finds 
muscular deviations in neurasthenics he should try 
to prove their nature. The patient should be made 
to feel as much at ease as possible. By exercising 
the various extrinsic muscles and diverting the 
attention for a moment the spastic condition may 
pass oi¥. The administration of general sedatives 
would tend to diminish but would not necessarily 
remove the deviation. It is probable that these 
measures, combined if necessary with repeated 
examination's, would clear up most of these cases. 
On second examination a different muscle may be 
producing a deviation or no deviation may appear. 

REFERENCES. 

1. Af¥ective Activity, Emotions as the Cause of Various 
Neurasthenic Bodily Diseases, New York Medical Jour- 
nal, April 4, 1914. 

2. The Rationale of Neurasthenia and of Disturbances 
of Arterial Tension, Boston Medical and Surgical Journal, 
October 18, 1917. 

3. The Etiology of Disturbances of the Heart Beat, Bos- 
ton Medical and Surgical Journal, October 25, 1917. 

4. The Explanation and Treatment of the Effort Syn- 
drome, Neurocirculatory Asthenia (Soldiers' Irritable 
Heart), Medical Record, July 26, 1919. 



SCARLATINA.* 

By Hyman I. Goldstein, M. D.. 
Camden, N. J. 

Scarlatina is the scientific name for scarlet fever 
and refers to any case of scarlet fever, whether 
mild or severe. Sydenham, in 1670, first assigned 
this condition as a distinct disease among the acute 
exanthemata. It is almost constantly present in the 
larger cities in North America, but outbreaks of 
scarlet fever in epidemic form are rare in India. 
Japan, Ceylon, Asia, Australia, and Africa. 

Etiology. — Klein's streptococcus, Edington and 
Jatnieson's Bacillus scarlatinae, and Mallory's pro- 
tozoon body were each thought to be the cause. 
Virulent streptococci are always associated with the 
special organisms of the disease itself, and are 
known to be the cause of many of the severe com- 
plications that arise in the course of this disease. 
Jochmann found streptococci as the most common 
and dangerous cause of the secondary infections of 
scarlatina, but is not the cause of the disease. 
However, while we do not know the cause of scar- 
latina, it has been definitely proved that the strepto- 
coccus is the main etiological factor in the tonsillar 
and pharyngeal pseudomembranous conditions of 
scarlatina. It has been definitely established that 
the Klebs-Loeffler bacillus is absent in the great 
majority of cases in the early scarlatinal angina. 

G. H. Memoine, in 117 cases of scarlatinal angina, 
found Streptococcus pyogenes alone in ninety-three, 

*Read before the Camden County, N. J., Medical Society, Feb- 
ruary 10, 1920. 



laiiuaiy 22, 1921.) 



GOLDSTEIN 



SCAKLATIXA. 



149 



while Klebs-Loeffler was found in addition in five, 
and the Bacillus coli communis in nine cases. In- 
clusion bodies have been found by Bernhardt, 
Dohle, Kretschmer, Hofer, and others. These in- 
clusion bodies are present in the polymorphonuclear 
cells of the blood in scarlatina. Klimenko's fusi- 
form bacillus and Schultze's Alicrococcus S are 
not the causes of the scarlatina. At present it may 
be stated that the specific germ of scarlatina has 
not yet been discovered. Mallory and Medlar 
thought scarlatina might be due to a strongly gram 
positive bacillus (Bacillus scarlatinae) ; however, 
this has not been proved. 

GENERAL SYMPTOMATOLOGY. 

The disease is commonly ushered in by sore 
throat, headache, vomiting, together with a very 
rapid pulse, sharp rise of temperature, and the ap- 
pearance of an erythematous rash, seen usually by 
the second day upon the upper thorax and neck, 
then spreading rapidly over the entire surface of 
the body. The tongue becomes reddened at the tip 
and margins with swollen papillae projecting, giving 
rise to the strawberry tongue. Tiie uvula is in- 
jected and the buccal mucous membrane is of a 
bright red tint. There is tenderness about the neck, 
pain over the submaxillary glands, which are often 
swollen. The maxillary, submaxillary, inguinal and 
axillary glands, especially the last two groups, are 
nearly always enlarged. Tonsils become red and 
swollen and may show whitish patches. Some cases 
may show early marked involvement of the pharynx 
and with but a poorly defined, irregular, or transient, 
rash, or the rash may be absent. Some cases may 
show a very faint rash for a few hours and slight 
redness of the pharynx and tongue — ^often attributed 
to stomach upset. These are tlie cases that may 
cause dissatisfaction and ill feeling between the 
patient's family and the attending physician, because 
of the question of diagnosis. The trouble is that 
many of our mild, atypical cases of scarlatina re- 
semble other minor ailments. It is, therefore, 
advisable to withhold, in all doubtful cases, the 
expression of a positive opinion for twenty-four to 
forty-eight hours, or at least until positive evidences 
of disease have appeared. 

The prodromal symptoms are of short duration, 
usually a few hours, and may be entirely overlooked. 
The first thing noticed may be an erythematous 
blush appearing first over the upper part of the 
chest, cheeks and neck (a bright, fiery red blush). 
The period of incubation varies from three to seven 
or eight days. This period may be shortened or 
prolonged. The more severe the epidemic the 
shorter is the incubation period. 

SIGNS AND SYMPTOMS. 

During the first twenty- four hours the charac- 
teristic early symptoms are the sudden and abrupt 
onset, vomiting (often early and persistent), head- 
ache, intense congestion of the faucial mucous mem- 
brane, sore throat, rapid rise of temperature, and 
rapid increase in pulse rate, and sometimes convul- 
sions. These suddenly appearing symptoms and 
onset are suggestive of scarlatinal infection. 

Vomiting. — Von Leube attributes great signifi- 
cance to early vomiting, and considers it an initial 



symptom of the greatest diagnostic value, occurring 
more often in scarlatina in childhood than in any 
other disease, with the possible exception of ]incu- 
monia. 

Throat. — ^Early sore throat is almost as conblant 
as the eruption. There is present usually from the 
first a diffuse, mottled, congested appearance of the 
uvula, soft palate, and tonsils, and the tonsils are 
swollen and the crypts filled with exudate. The 
eruption in the throat makes it sore. 

Skin. — The early rash develops as a rule within 
the first twenty-four to thirty-six hours, and ap- 
pears as a widely scattered punctate blush, and 
differing from the sharply defined, pin head, slightly 
elevated rash of measles and the areas of pale .-^kin 
with the measles rash are absent in scarlatina. 

At the end of the first forty-eight hours, the 
real scarlatinal rash has made its appearance, first 
upon the upper thorax and then spreading quickly 
over the neck, chest, and extremities, but only 
slightly upon the face. The rash is a diffuse, scarlet 
blush made up of minute brightly red injected 
puncta, very slightly elevated and closely studded 
together, forming a uniform or finely mottled sur- 
face. The region about the mouth is comparatively 
free from rash. The rash develops more rapidly 
in blond, healthy, full blooded children than in 
darker skinned or pale children. The rash is more 
pronounced over areas exposed to irritation or pres- 
sure, such as the buttocks, back, bend of elbows, 
groins ; upon streaking or pressing the skin the red 
blush of the eruption momentarily pales. This pal- 
ing is not characteristic of scarlatina in any w ay. 

As stated previously, and now emphasized again, 
the places where the rash appears earliest are the 
upper thorax and neck, especially down over the 
subclavicular regions, far less commonly upon the 
small of the back. In a few hours the rash spreads 
all over and at the end of ten to twenty hours 
reaches the legs and entire trunk. I again empha- 
size the fact that upon the face true scarlatina rash, 
differing thus from measles and smallpox, is much 
less marked, and occurs only upon the cheeks and 
forehead, usually the lips and nose being free, giving 
a peculiar white ring, which is quite striking. The 
dorsal surfaces of the hands and feet show a marked 
eruption, while the plantar and palmar surfaces do 
not appear so injected. The rash remains at its 
maximum for from one to three days. The remit- 
tent intensity of the rash has been emphasized by 
Henoch. 

Pulse rate. — The pulse rate is markedly increased 
out of all proportion to the fever. From the second 
to the third day the rash begins to fade and the 
temperature comes down slowly but the pulse con- 
tinues quite rapid. In measles there is often an 
abrupt fall in temperature. 

Tongue. — The appearance of the tongue and 
throat are almost pathognomonic of the disease in 
some cases. The eruption makes the tongue sore 
at times, and results in the well known strawberry 
tongue, as mentioned above. The tongue loses its 
heavy coating after the second day and becomes 
deeply injected, the papillte at the tip and along the 
margins becoming more prominent, giving rise to 
the katzcnzunge. 



150 



GOLHSTEfN: SCARLATINA. 



[New York 
Medical Journal. 



Enlarged glands. — \'on Jiirgenscn emphasizes the 
diajjnostic value of early enlargement of the in- 
guinal glands in scarlatina. Schamberg also has 
emphasized the great frequency of enlargement of 
the inguinal, axillary, and maxillary glands. He 
found the inguinal glands enlarged in all cases, the 
axillary in ninety-six per cent., the maxillary in 
ninety-five per cent., and the posterior cervical in 
seventy-seven per cent, of the cases. The study of 
these one hundred cases by Schamberg showed that 
the maxillary glands commonly attained the largest 
size, and also most frequently underwent suppura- 
tion. In all of the one hundred cases studied, on 
the second or third day of the disease the enlarge- 
ment of the lymphatic glands was well marked. 

Polymorphonuclear Icucocytosis. — This condition 
is always present. In measles there is a leucopenia. 
Dohle, in thirty scarlatina cases, found inclusion 
bodies in the polymorphonuclear leucocytes. He 
did not find them after the sixth day of the disease. 
Kret.schmer, and Nicoll and Williams, also found 
these bodies in the blood smears in forty-five out of 
fifty-one cases. Isenschmid and Schemensky have 
found them in practically all the cases of scarlatina 
in the early stage. They are not found in German 
measles, measles, diphtheria, or whooping cough. 
The most characteristic inclusion bodies are those 
of a triangular form with a long, taillike end. They 
may be found in pneumonia. 

Rumpel-Leede sign. — Rumpel (1909), Leede, and 
Jampolis have reported and recommended as a sug- 
gestive diagnostic sign the appearance of petechije 
in the skin on the inner surface of the elbow joint, 
when the .skin is stretched until it becomes anemic, 
after a broad constricting band above the elbow- 
joint has been previously applied for ten or fifteen 
minutes and then loosened. A negative reaction is 
perhaps a greater indication that scarlatina is not 
present than is a positive reaction that it is present. 
Jampolis found it in 199 out of 200 cases. 
Bennecke confirmed the diagnostic significance of 
the Rumpel-Leede phenomenon. A venous stasis 
only being produced in the arm, the arteries being 
left alone, the hemorrhages appear at the elbow in 
from five to twenty minutes — punctate or larger, 
in some cases becoming confluent. He found them 
in nearly all cases. 

Desquamation. — The eruption is due to an in- 
flammation of the skin and to very minute vesicles 
which form in the deeper layers of the epithelium 
and loosen the cells. This loosened epithelium peels 
ofl:', and gives rise to the characteristic desquama- 
tion. Desquamation usually begins in from ten to 
twenty days after the onset of the disease. It 
begins around the roots of the nails, the palms, and 
soles, and extends over the whole body. 

Schumacher states that desquamation is not a 
positive sign of recent .scarlet fever, as scarlet fever 
can exist without any subsequent desquamation, and 
that desquamation may be the result of a number 
of constitutional diseases of long duration, as i)neu- 
monia and tuberculosis, or some local inflammatory 
condition of lengthy duration, as sunburn or ivy 
poisoning; or the internal ingestion of such drugs 
as arsenic ; or the external application of strong 



anti.septics, such as phenol or formaldehyde gas. 
Desquamation begins first where the rash was first 
seen and from where it first disappears, namely, the 
upper thorax and neck. 

Wassermann reaction and Babinski sign. — P. Teis- 
sier and R. Benard found a positive Wassermann 
reaction in eighty-four per cent, of the cases of 
scarlatina in the Hopital Claude- Bernard. The 
Babinski sign in scarlatina and diphtheria has been 
reported to have occurred in a rather large percent- 
age of cases, nineteen to twenty-five per cent, of 
all cases. 

Transient albuminuria. — Early in the course of 
the disease, albuminuria is seen in seventy-five to 
ninety per cent, of all cases, according to Eichhorst. 

Age. — The greatest number of cases occur be- 
tween the ages of one and five or six years. 
McCoUom, at the Boston City Hospital, reported 
that seventy-five per cent, of patients were between 
two and ten years of age. 

IMMUNITY. 

As a rule one attack protects against a sulxsequent 
infection. Second attacks have been reported. 
Others have reported even third attacks. One must 
not make a positive diagnosis of a second attack of 
scarlatina without first excluding all other possible 
conditions, and without a careful study of all the 
presenting symptoms and signs and a thorough study 
of the history of the case. Henoch has seen but one 
authentic case of a second attack of scarlatina. 
According to Korner, when a second attack occurs 
it usually follows from two to six years after the 
first (which first attack usually occurs before the 
age of ten years). Murchison has reported a third 
and Stiebel a fourth attack of scarlatina. The vari- 
ous erythemata must, of course, be excluded, such 
as drug erythema; measles, rubella, antitoxin ery- 
themas, toxic or simple erythemas, erythema scar- 
latiniforme, erythema scarlatini forme desquama- 
tivum, etc. Jacobsen, in April, 1914, reported the 
case of a family of four children who had scarlatina 
in 1908 and 1911. Over a year later the children 
had scarlatina again, each one of the children having 
a typical attack. The second attack was more seri- 
ous than the first in all, and one girl, eight years old, 
died from myocarditis. 

TYPES AND VARIETIES. 

Numerous varieties or types of scarlatina have 
been described, such as the following: 

1. Scarlatina anginosa. 

2. Scarlatina maligna (toxic). 

3. Scarlatina modificata : 

a Scarlatina miliaris. 

b Scarlatina laevigata. 

c Scarlatina laevis. 

d Scarlatina sine exanthemata. 

e Scarlatina hemorrhagica. 

f Scarlatina variegata. 

g Scarlatina sine angina. 

h Scarlatina sine fehrc. 

A simple classification is this : 

1. Well developed and .severe cases of scarlatina. 

2. Mild cases, in which there is sore throat, and a 
slight (evanescent') rash, with subsequent desqua- 
mation or peeling. 

3. Still milder case.s — not a sufficiently concen- 



J;iiiuar> 22. 1921.] 



GOLDSTEIN: 



SCARLATINA. 



151 



tratecl infection to cau.se a rash, hut which produces 
a sore throat, and iDossihly exfoliation of the tongiie 
(strawberry tongue). These sul)cases are of the 
greatest importance from a public healtli viewpoint. 
The eruption may at tii^ies be abortive, or not seen 
at all, or the rash fails to appear (scarlatina sine 
eruptione). It is possible that the rash appears, but 
is so faint and evanescent as to go unnoticed. 

MORTALITY. 

In a .study of 1,153 cases of scarlatina by L. I. 
Dublin, there were ninety deaths, or a mortality 
rate of 7.8 per cent. ^IcCoUom found an average 
of 8.4 per cent, mortality rate in 37,810 cases in 
Boston in twenty-eight years. In 32,317 cases of 
scarlatina during a twelve year period in Phila- 
delphia (1898-1910). 1,759 deaths occurred, or a 
mortality rate of slightly over five per cent. 

Dublin found eighty-two per cent, of all cases 
(1,153 in the series) were among children between 
two and ten years. The greatest disposition to the 
disease is found among children three to seven years 
of age, according to Dublin. According to Osier, 
ninety per cent, of all scarlatina deaths are of chil- 
dren under ten years. Dublin's figure was ninety- 
tw^o per cent. The mortality averages from five to 
twelve per cent., varying in different localities and 
in different epidemics, depending often on the sea- 
son of the 3'ear. 

SEOUELvB AND COMPLICATIONS. 

Otitis. — According to Carter, otitis is perhaps the 
commonest complication of scarlatina. According 
to Holt, perhaps seventy-five per cent, of the severe 
cases show otitis. In 4,015 cases analyzed by 
Caiger, 11.05 per cent, showed otitis media. Bader 
and Guinon found that thirty-three per cent, of all 
the cases of scarlatina showed mild or catarrhal 
otitis media and the purulent form in 4.5 per cent. 
Ten per cent, of acquired deafness has its origin 
in scarlatina. Barasch found among 1,438 cases 
13.8 per cent, showed otitis. Fisher reported middle 
ear trouble in twenty per cent, of cases. Richard- 
son, of Providence, in a letter to me, states that 
about twelve per cent, of the cases show acute otitis 
media with less than one half to one per cent, 
developing mastoiditis. Finlayson, in 4,397 cases 
studied, found otitis in ten per cent. 

A'cpliritis. — Osier records the presence of nephritis 
in from ten to twenty per cent, of his cases. H. 
Barasch reports that 16.1 per cent, of 1,438 cases 
were complicated by nephritis, at the Urban Hos- 
pital, Berlin. Xo case, however mild, is wholly 
free from the danger of a subsequent severe renal 
inflammation. The occurrence of nephritis during 
the course of scarlatina is due to the circulation in 
the blood of the specific virus or toxin wliich acts 
as a direct irritant. Nephritis appears less fre- 
(|uently in young adults than in childhood. Scarla- 
tinal nephritis develops late in first or early in second 
week — from the tenth to the twentieth day of the 
disease. 

There may be, 1, early or initial mild nephritis; 
2, septic nephritis, and, 3, postscarlatinal nephritis. 
Out of 1,200 cases, Richardson found, two or three 
years ago in a study of the records of the Provi- 
dence City Hospital, about one per cent, nephritis. 



with no deaths. However, since that time he found 
the incidence in nephritis was much greater in that 
one year than in all the cases he had previously 
put together. Wilson, of the Bureau of Hospitals, 
New York city, states in a communication to me 
that the frequency of complications in the order of 
their occurrence are endocarditis, angina, arthritis, 
nephritis, and mastoiditis. Complications are very 
much more frequent where the patients are per- 
mitted to get out of bed too soon after the fall of 
temperature. Bara.sch reports among the 1,438 
cases above mentioned the following complications : 
Nephritis, 16.1 per cent.; otitis, 13.8 ])er cent.; 
rheumatism, 5.9 per cent.; sepsis, 9.1 per cent.; 
endocarditis, 1.3 per cent.; late involvement of 
glands in the neck, 33.4 ])cr cent, and 16.4 per 
cent, of the total were complicated by diphtheria. 

Heart. — The heart is very .susceptible to the scar- 
latinal poison, shown by the marked tachycardia and 
irregular, small, rapid pulse. The mural endo- 
cardium (myocarditis) is probably much more often 
affected than the valves themselves. 

Acute endocarditis is apparently rare. Murmurs 
may often be heard, probably due to tlie toxic myo- 
carditis. The rapid and at times irregular pulse is 
chiefly seen early in the attack. Later on the lieart 
sounds may lose the normal tone. This evidence 
of cardiac weakness may be due to endocarditis or 
myocarditis — probably the latter, becau.se it is 
usually the endocardium of the heart wall, rather 
than of the valves, that is involved. In cases of 
nephritis, there is seen in children acute dilatation 
and hypertrophy of the left ventricle. 

A. Stegemann, from an examination of forty- 
nine cases, found in toxic cases of scarlatina of 
short duration, the parenchymatous changes in the 
heart muscle slight. In the infectious cases of 
long duration there were acute parench3matous 
degenerations and necrosis. The number and size 
of the Nissl bodies were markedly decreased in 
severe toxic cases, in contrast with the infectious 
cases. He belieVes that in severe toxic cases of 
scarlatina, of short duration, the cause of the heart 
weakness lies in pathological clianges in the lieart 
ganglia. 

Adenitis. — Fisher reported that in six thou.sand 
cases fourteen per cent, had adenitis. The fre- 
quency of this complication varies considerably ; it 
often occurs in the early stage of the disease or at 
times in the second or third week. 

Scarlatinal sy]ioz'itis. — This is comparatively com- 
mon. Serous (simple) .synovitis is more common, 
and purulent arthritis may occur, but is not fre- 
quently seen. Synovitis occurs in about seven per 
cent, of the cases, is usually transient, nearly always 
apjiearing from the fourth to the tenth day, and in 
seventy-two per cent, of the cases affects the wrists, 
according to Marsden. Carslow in 533 cases found 
.synovitis in sixty. It is most frec|uent in cliildren 
past five years of age. 

Phlebitis. — This complication is very rare. 

Bronchopneumonia. — Bronchopneumonia, and 
even true croupous pneumonia, occur more fre- 
quently than we realize, particularly in nephritis 
cases. Pyemia and abscess of the lungs may occur. 



152 



GOLDSTEIN: SCARI.A TINA. 



[New York 
JIedical Journal. 



Acute psychosis. — Psychosis may occur in con- 
valescence. 

Diphtheria. — Diphtheria complications occur as a 
rule late in the course of the disease, and often after 
complete subsidence of the primary throat inflam- 
mation. Paralysis may occur in these cases. 
Henoch has never seen oculomotor or palatal 
])ara]ysis following scarlatinal angina, except in 
those few cases complicated by a true diphtheria. 
Richardson states that among his cases diphtheria 
developed in only about one to three among 
two to three hundred cases of scarlatina every 
year. R. J. Wilson, of the New York Department 
of Health, states that diphtheria is an infrequent 
complication of scarlet fever, and since the advent 
of the Schick test it has been almost entirely 
eliminated as a complication in the wards of the 
hospital. It should be remembered, however, that 
secondary' infection by the Klebs-Loeffler bacilli 
may occur, most likely after the first week. This 
may be easily overlooked. It is therefore advisable 
to examine the throat at each visit, and if suspicious 
to take a culture smear at once. 

DIAGNOSIS. 

Difi'erential diagnosis must be made from measles, 
Duke's (fourth) disease; drug eruptions due to 
quinine, belladonna, antipyrine, opium, chloral, 
potassium bromide, potassiufti iodide, mercury and 
antitoxic sera; rubella (German measles); toxic 
transient erythema, sometimes seen in diphtheria; 
erythema scar latini forme, erythema scarlatiniforme 
desquamativum, and simple erythemas with or with- 
out tonsillitis (streptococcic). However, suffice it 
to say that in the large majority of cases the short 
incubation period (stadium incubation — two to 
seven days), the very short prodromal stage (stadium 
prodromorum of a few hours — twenty-four or less), 
the early vomiting, the early sore throat, the charac- 
teristic punctate fiery red eruption (stadium erup- 
tionis), the very rapid pulse — 140-165, out of all 
proportion to the temperature and general condition 
of the patient; Pastia's sign — an intense continuous 
linear exanthem in the skin folds at the bend of 
the elbow ; the Rumpel-Leede phenomenon ; the 
presence of inclusion bodies in the polynuclear cells 
of the blood prior to the sixth day, true leucocytosis 
(an absolute and relative increase of the polymor- 
phonuclears) ; the rapidly growing cultures (throat) 
of the Class coccus and the strawberry tongue — 
several or all of these symptoms will aid in making 
the correct diagnosis of scarlatina. 

In measles we have a leucopenia, Koplik spots, 
the peculiar rash, and the catarrhal symptoms and 
the marked contagiousness of the disease render 
valuable aid in diagnosis. Measles is liable to be 
mistaken for scarlatina only in special cases. In 
scarlatina there is tenderness about the neck, with 
pain on palpating the submaxillary glands, which are 
often swollen. In scarlatina, too, the congestive 
disturbance of the mucous membranes is mainly 
confined to the pharynx, tonsils, and larynx. There 
is much more photophobia and dread of light in 
measles than in scarlatina. In measles, too, there is 
a much more general catarrhal condition of the 
upper air passages, with coryza and the charac- 



teristic dry, croupy, hoarse, barking cough. The 
buccal mucous membrane in scarlatina as a rule is 
of a bright red tint and the uvula is much congested ; 
in measles (rubeola), there is a pale bluish tint, 
with a coated tongue (whitish fur) with a few 
scattered enlarged reddened papillae ; the rash in 
measles does not appear until the fourth day, while, 
as stated above, the prodromal stage in scarlatina 
does not last longer than twenty-four hours. The 
dark red maculje and papules of measles, with the 
slightly cyanotic features, certainly differ from the 
bright red punctate rash of scarlatina. The first 
lesions in measles appear on the upper part of the 
forehead, on the temples behind the ears, and on 
the sides of the neck. Later it appears about the 
eyes, mouth, and on the chin. In scarlatina, the 
rash first appears on the upper thorax and neck. 
Diarrhea is often seen in measles, rare in scarlatina, 
although it has been known to occur at times early 
in the disease. 

In rubella the rash appears first on the face and 
is very evanescent and is never entirely confluent, 
being always "measley" or "spotty" in appearance. 
Constitutional symptoms, otitis, severe pharyngeal 
involvement, and albuminuria, are almost unknown 
in rubella. This is a most benign short and mild 
infectious disease. The onset even is mild and slow 
and insidious, while in scarlatina it is always sud- 
den. 

In a report of 150 cases Griffith found some 
congestion of the upper portion of the anterior pil- 
lars of the fauces with some swelling of the tonsils 
in rubella, and Forchheimer described his small, 
discrete, dark red (not dusky) papules on the soft 
palate, remaining only about twelve to fifteen hours, 
and appearing simultaneously with the exanthem in 
rubella. Rehn also observed similar lesions on the 
soft palate and in the conjunctivae. Bolognini's 
pathognomonic sign of measles consists of a fine 
peritoneal crepitation or friction — as if two bottles 
were rubbed together, when the pulps of the fingers 
are applied with gentle pressure to the relaxed 
abdomen, while the legs are flexed. However, this 
sign is present in other affections and not of much 
diagnostic significance. 

In rubella, too, we have adenopathy in ninety-six 
to ninety-eight per cent, of all cases, the superficial 
or postcervical and the maxillary glands being most 
frequently involved. The occipital and the anterior 
and posterior auricular are frequently palpablj' en- 
larged. Finally, in rubella, the pinkish maculae and 
papules are very often discrete, but frequently be- 
come confluent in a few hours. They are first seen 
on the face and scalp, and next on the neck and 
upper chest, without any tendency to form groups, 
crescents or clusters (as in measles). Most impor- 
tant of all, the prominence of the eruption varies 
in different parts of the body. Thus the eruption 
has already begun to fade on the face before it has 
fully developed on the trunk : it is usually nearly 
gone on the face before it begins to fade on the 
trunk, and it is usually nearly gone on the trunk 
before the legs are involved. This characteristic 
appearance of the eruption on various parts of the 
body helps to distinguish this disease from scarlet 
fever and measles. 



January 22, 1921.] 



GOLDSTEIN 



SCARL.rriXA. 



153 



ERYTHEMA SCARLATIXIFORME DESQUAMATIVUM, 
ERYTHEMA SCARLATINIFORME, ERYTHEMA 
SCARLATINOIDE. 

There are several grades of this condition, mild 
and severe. The rash is often almost continuous 
over the entire surface. In some cases the rash is 
of a morbilHform type, in others of a scarlatinoid 
form, which at times is even punctiform in appear- 
ance at first, later becoming a uniform bright pink, 
fiery red, or sluggish livid red color. Usually the 
attadk is ushered in with mild or more severe febrile 
symptoms. Often the constitutional symptoms abate 
when the erythematous blush appears. In other 
cases, the general symptoms continue for several 
days after the eruption appears. The rash begins to 
subside in two, three, or four days with desquama- 
tion. Recurrences are frequently seen. The later 
attacks are usually mild. The rash is not usually 
quite so general as in scarlatina. The course usually 
runs from 10 days to three weeks. Typical straw- 
berry tongue and adenopathy are usually absent. 
The anginal symptoms are very slight or entirely 
absent, and the disease is noncontagious. 

Case I.— C. S., attorney, twenty-four years of 
age, male, white. Had had scarlet fever when six 
years old. In 1917 and 1918 he had had attacks 
of red rash, with itching and swelling, puffiness of 
head and face, a trace of albumin in the urine, and 
some sore throat. The attacks lasted about ten 
•days. With this diffuse uniform red rash there 
would be urticaria, large wheals appearing over 
various parts of the body, followed later by some 
desquamation. The third attack began early in 
December, 1919, with itching and burning, swelling 
of the entire face and scalp, numerous large wheals 
appearing all over the trunk, back of neck and 
thighs, with some fever and sore throat. Shortly 
afterward, a uniform fiery scarlatinoid (punctate) 
rash appeared all over the body, particularly marked 
o\ er the abdomen, neck, and back. The throat was 
considerably congested, and soreness was complained 
of. T\-pical strawberry tongue was absent. 

Throat cultures showed at first only streptococci, 
later staphylococci also. The rash began to fade 
after the fifth or sixth day. There was still some 
eruption over the abdomen and back on the seventh 
and eighth days of the attack. The urine showed 
a trace of albumin; specific gravity. 1,013; a few 
Ted blood cells ; squamous, renal epithelia ; a few 
pus cells ; ammonium urates ; total solids 30.3 grams 
to the litre; urea 1.3 per cent.; no acetone, no indi- 
can, no sugar, no casts. Desquamation was a prom- 
inent feature in the case, but it was scarcely notice- 
able on the hands and feet. 

At first, the case certainly strongly suggested 
scarlatina, and this, therefore, would be a fourth 
attack, if the patient was correct in his description 
of the attacks of 1917 and 1918, and if the historv- 
of true scarlatina when six years of age had refer- 
ence also to a similar attack of recurrent erythema. 
In my opinion this was a case of erythema scarla- 
tiniforme desquamativum ( ervthema scarlatinoides 
recidivans, or recurrent exfoliative erythema). 

Carter describes and reports a similar case in 
a young woman, aged twenty, who had four attacks. 



This was Dr. Corlett's patient, and shows the diffi- 
culty of establishing a diagnosis without reference 
to the history, and the importance of remembering 
that the appearance of a characteristic desquamation 
is by no means always an infallible si^n of recent 
scarlatina. In my case, albuminuria, with head- 
ache, sore throat, fever, extensive eruption, and 
marked desquamation occurred in three attacks in 
1917; 1918, and 1919. Whether the attack in child- 
hood was scarlet fever or the first attack of scarla- 
tinoid erythema resembling the others, I do not 
know. The typical changes seen in the tongue from 
the third to the sixth day in true scarlatina, were 
absent in- my patient, although the edges and tip 
of his tongue were raw and congested. Desquama- 
tion in this case continued for only a few days, 
when it ceased. In true scarlet fever the desqua- 
mation usually lasts for two to six weeks. 

Recurrent attacks of scarlatina are very rare. 
Holt says he has never seen an undoubted instance 
of a second attack in the same patient. Kinnicutt 
reported two attacks within eight months in a boy 
of five years. Pritchard reported a case in which 
three attacks occurred within two years. Henoch 
only knew of one authentic case of a second attack 
of scarlatina. Statements by physicians that they 
have seen two and three attacks of scarlatina in 
the same patient should be accepted with some doubt 
because of possible errors in diagnosis and mistakes 
in the history of the cases. 

FACTS IMPORTANT TO REMEMBER. 

1. At present there is no certain test for scarla- 
tina, just as there is no certain test for influenza and 
a few other common infectious diseases. 

2. Many patients are not even sick enough to have 
a physician, and have only a very faint eruption, 
later followed, however, by desquamation. This is 
the best sign we have. 

3. If a child has a desquamation of the skin two 
or three weeks after a slight attack of illness with 
slight fever, it is usually safe to say that the child 
had scarlet fever. 

4. The causative organisms of scarlatina are 
found in the discharges of the nose and mouth, and 
are not found in the skin, nor in the scales (even 
during desquamation). The organisms may be 
present in the discharges from the ear and abscesses. 

5. The mild cases, the unrecognized cases, those 
with discharge from the nose, throat and ears, and 
abscesses, are the carriers that cause most of the 
scarlatina cases. 

6. Scarlatina is transmitted by contact with fresh 
discharges of active cases or with the discharges of 
carriers. The organisms produce the disease in 
from two to seven days after infection. Therefore, 
if a child has been exposed to infection and does 
not become ill within a week, he may safely be 
allowed to mingle with other children. 

7. One attack of scarlatina usually confers life- 
long immunity. Carriers working in dairies or in 
milk establishments may contaminate the milk, and 
so help to spread the disease through infected milk. 

PROPHYLAXIS. 

1 . Early discovery of cases is an important factor 
in the prevention of the spread of this disease. We 



1 54 GOLDS 'FEIN : SCA RLA TINA . 



know that every case of scarlatina conies from a 
previous case. Unrecognized cases, missed cases, 
tvirenty-foiir hour cases, and atypical cases, are the 
ones that may be caught if the physicians, health 
ofificials. school doctors, school nurses, and school 
teachers will make more thorough and complete 
examinations. In suspected cases the patients 
should all be completely stripped and examined. 

2. Prompt isolation. 

3. Proper disposal of all discharges and excretions. 

4. Protection of school children. 

5. Proper treatment at home or in a contagious 
disease hospital. 

6. Public health propaganda. 

7. Proper attention to personal cleanliness, and 
suitable precautions taken by the attendants and 
those coming in contact with the case or cases includ- 
ing the physician. 

8. Proper attention to toilet articles, dishes, milk 
bottles, doorknobs, and any other article that may 
have been contaminated with the fresh discharges 
of the patient. 

Disinfection or fumigation after recovery is un- 
important. Desquamation is unimportant, except, 
of course, the possibility that the skin may be con- 
taminated by the infected or organism bearing dis- 
charges from the nose, throat, and ears. The infec- 
tive material in scarlet fever is found in the dis- 
charges from the nose, throat, and ears, and in the 
urine and feces. Proper attention to these should 
be given, as mentioned above. It has been shown 
that ordinary cleanliness is sufficient to render arti- 
cles free from scarlatina germs, and that these germs 
are not longlived, and are readily killed. Children 
who live in a house where there exists an active 
scarlet fever case must not be allowed to attend 
school or play with other children, because they 
may come in contact with the sick child in the house 
unbeknown to anyone. However, if children who 
have had the disease and are immune, leave the 
house, they may be allowed to return to school. 
If nonimmune children leave the house, and after 
a period of observation for seven days do not pre- 
sent any symptoms, they may be allowed to return 
to school. 

TREATMENT. 

Avoid meddlesome treatment ; avoid overtreat- 
ment. 

Nose and throat. — Salt solution is the simplest 
and most efficient cleansing agent for the nose and 
throat. Liquor antisepticus alkalinus may also be 
used, with a nasal douche, every two or three hours. 
An ice bag constantly applied over the throat gives 
relief. Avoid strong, irritating, unpleasant, throat 
gargling solutions. 

Blood scrum. — The blood serum from patients 
who have recovered from scarlatina has been used 
with excellent results. An easy and practical way 
is to withdraw a few ounces, say four, five, or eight 
ounces, of the blood from the donor and immedi- 
ately inject the whole blood into the gluteal region 
of the patient. (Titrate solution is fir.st drawn 
through the luer syringe.) This blood is soon 
absorbed and the dangers of intravenous injection 



[New York 
>[edical Journal. 

and marked anaphylactic reactions are thus avoided. 
It is important to know that the donor is not 
syphilitic. 

Rest and fresh air. — The patient should be kept 
in bed, even in the mildest cases, and not covered 
too heavily. Plenty of fresh air and thorough ven- 
tilation are most important. The temperature of 
the room should be kept at about 65°-70°F. (23° C.) 
Avoid exposure to drafts. The patient should be 
kept in bed for a week, if possible, after the sub- 
sidence of the active febrile stage. In this way 
only can the danger of late renal complication be 
avoided, while daily examination of the urine is the 
only guide as to just what changes may be taking 
place. The phenolphthalein renal function test may 
be tried. 

Skin. — Throughout the course of the disease a 
tepid sponge bath should be given once or twice a 
day. These sponge baths diminish the tension of 
the skin and aid in skin elimination, besides being 
extremely grateful to the patient. For the itching, 
and later for the desquamation, cold cream or 
cacao l)utter or a mixture of lanolin, petrolatum and 
olive oil, with a little phenol (one or two per cent.), 
may be used. Menthol, one half of one per cent., 
may also be added for the relief of the itching. 

Unfortunately, there is as yet no specific treat- 
ment for scarlatina. Huber and Blumenthal ( 1 ) 
have reported the use of serum from the blood of 
convalescent scarlatinal patients with varied results 
in a series of thirteen cases. E. M. Landis (2) has 
reported a striking case of recovery following the 
use of antistreptococcic serum. 

A. Baginsky (3) reported a series of fortv-eight 
cases of scarlet fever, treated with Marmorek's anti- 
streptococcic serum, with a mortality of 14.6 per 
cent. Antistreptococcic serum and streptococcic 
vaccines may, theoretically at least, be of real value 
in all cases of scarlatina complicated bv strepto- 
coccic angina, ear infections, and abscesses. In 
these latter a mixed staphylostreptococcal serobac- 
terin may be tried. 

In all septic cases, and in cases threatened with 
uremia, the use, subcutaneously and even intraven- 
ously, of large amounts of sterile normal salt solu- 
tion has been advised by Forchheimer, E. P. Carter, 
and others. The object is to dilute the poison cir- 
culating and as a mechanical aid to diuresis and the 
elimination of toxins. It is possible that in the 
severe toxic cases much might be gained by such 
measures if adopted early. In the vast majority of 
cases with slight sore throat, little fever, and only 
mild constitutional symptoms, all the treatment 
necessary will be isolation, rest in bed, diet and 
nursing, local care 'of the nasopharynx and .skin, 
and the administration of an alkaline mixture as 
follows : 

Sodi citratis dr. iii 

Syrupi fl. dr. iv 

Liq. potassii citratis, ) ... 

T . ^ ^- ( aa q. s. 4 oz. 

Liq. amnion, acetatis, J 

M. Sig. : One fl. dr. in sweetened water every two or 

three hours. 

Fci'er. — In reference to the use of antipyretic 
drugs, Osier has properly stated that medicinal anti- 



January 22, 1921.] 



GOLDSTEIN 



SCARLAIINA. 



155 



pyretics are not of much service in comparison with 
cold water. Osier, Henoch, Moizard, Steffen, Cur- 
rie, Von Jiiryensen, Jacohi, Carter, and many others 
have recommended cool tepid sponge baths as the 
best means, the safest and most reliable method we 
liave for reducing the temjjcrature in scarlatina. 

Bowels. — Mild saline laxatives or small fractional 
doses of calomel, followed by an evacuating enema, 
are indicated. 

Stimulation. — When the pulse is weak, soft, and 
of low tension, .some form of digitalis may be used. 
As soon as the first sound .of the heart becomes 
weak or the heart sounds lose their normal tone and 
any threatening change is noted in the pulse, stimu- 
lation should and must be resorted to and insisted 
upon. Brandy or whi.skey in suitable doses may be 
given cautiously. Strychnine in small doses, with 
or without iron, may be given. Camphor, one to 
three grains, hypodermically, or caffeine sodium 
benzoate are of the greatest value in this condition. 
Sometimes, especially if the cardiac weakness is 
associated with marked restlessness, delirium and 
grave toxic symptoms, very small doses of mor- 
phine as recommended by Jacobi, seem sufficient, 
together with bromides and hot baths. Musk, if 
obtainable, can be tried in doses of one half to three 
grains. All my patients receive alkaline entero- 
clysis. Bicarbonate of soda solution is given by 
rectum in all cases, together with alkaline drinks by 
mouth. Plenty of orange juice, lemonade and 
water, milk, buttermilk, ice cream, orange albumin, 
kalak water, and Vichy, are allowed. 

Other complications, such as earache (otitis), 
lymphadenitis, severe anginal complications, arthritis, 
endocarditis, pericarditis, bronchitis, pneumonia, 
pleurisy, stomatitis, gastroenteritis, diarrhea, and 
nephritis — -all require attention and treatment as in 
^ any other infectious disease. Jt is unnecessary to 
go into details in the treatment of these complica- 
tions in a paper of this kind. Diphtheria may be a 
complicating infection in scarlatina, and when it 
does occur, as shown by positive throat cultures of 
Klebs-Loeffler bacilli, dii)htheria antitoxin should be 
immediately injected and the heart stimulated. 

I do not believe that either belladonna or arsenic 
have any protective powers against scarlatina. 
Illingworth suggested that biniodide of mercury 
would cut short an attack and cause the rash to 
disappear rapidly. ^lehary believed salicin had 
some abortive power. Chlorate of potash should 
not be used in scarlatina. Very often I have found 
warm tub baths relieve nervousness and restlessness 
and reduce the temperature one or two degrees very 
promptly. Sponging — continued for ten minutes — 
with warm water (90°F.), with or without alcohol, 
may be substituted for the bath. Water should be 
applied freely and, if necessary, cooler water (70°- 
80° F.) may be used. A good reaction should be 
obtained ; the patient must not get blue or remain 
cold. 

Moser reported excellent results from a poly- 
valent antistreptococcic serum. The serum may be 
u.sed against the septic manifestations. Its early 
use may be of value in protecting patients against 
subsequent streptococcic infections and serious com- 
plications be avoided. McCollom has recommended 



insufflations of calomel, instead of irrigations, for 
the nasopharynx. 

R. Koch reports excellent results in the treatment 
of scarlet fever with intravenous injection of 100 
c. c. of serum taken from convalescents; that is, 
at about the third week of the di.sease. Among 
280 cases of extremely severe scarlet fever, only 
one patient died, and this was a child who was 
moribund when first seen, dying in an hour. Con- 
valescent and normal serum act alike, but the for- 
mer is more powerful. It requires 50 c. c. for very 
young children and 100 c. c. for older ones; it is 
better to mix the serums of several convalescents. 
It is most efficient during the early stages of the 
disease. Koch regards it as an almost absolutely 
certain weapon during the early stages of the dis- 
ease if given intravenously and in sufficient doses. 

A. Zinglier, of New York, treated scarlatina with 
fresh blood from convalescent patients. He injected 
directly or first citrated by adding one c. c. ten per 
cent, sodium citrate solution to one ounce of whole 
blood, making the final dilution of the citrate 0.33 
per cent. Four ounces can easily be injected in a 
young child, and eight ounces into an older child. 
He reported treating fourteen toxic cases in this 
way. The majority of the patients were very toxic 
and often delirious. 

Gabritschew.sky, in 1905, introduced the use of 
streptococcic (cocci from cases of scarlatina) vac- 
cine for preventive inoculation, and was used quite 
extensively in l\u^>ia. R. M. Smith concludes that 
Gabritschewsky's vaccines do appear to have some 
influence in controlling epidemics of scarlatina, and 
should lie tried. Russian physicians used it exten- 
sively. Watters tried this preventive inoculation on 
twenty-one nurses who had not had scarlet fever 
previously. 

Reiss and Hertz used the mixed serum from 
several scarlatina cases (convalescent), injected it 
intravenously in large doses. They believe in its 
preeminent efficacy, and as actually life saving, in 
many cases. Fifty c. c. for children and 100 c. c. 
for adults. Injections must be commenced before 
the fourth or fifth day to be promptly effectual. 
Normal serum seemed entirely impotent. They took 
the serum from convalescents between the eighteenth 
and twenty-fourth days, after negative Wassermann 
and excluding tuberculosis and septic ca.ses. 

Meltzer, Auer, Morgenroth, and Levy have shown 
that absorption from muscle is very much faster than 
it is from subcutaneous tissue. In fact, the rapidity 
of action of substances so injected approximates 
very closely that following an intravenous injection. 
Twenty-three patients treated at Willard Parker 
Hospital with intramuscular injections of blood. 
Distinct beneficial results were noted in the very 
severe cases by Abraham Zingher. 

D. Maclntyre treated septic scarlet fever cases 
with autogenous streptococcic vaccine in the acute 
stage. All the patients recovered. John A. Kolmer 
does not think streptococcic immunization has any 
value as a prophylactic measure against scarlatina, 
{•".pinephrine, in ten to twenty drops at a dose by 
mouth, was used by Paoloantonio in kidney cases 
of scarlatina, and in urgent cases with hematuria 
he gave it sulicutaneously. 



156 



CUMSTON: SEBORRHEA OF SCALP. 



[New York 
Medical Journal. 



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20. Waiters: Journal A. M. A-., February 24, 1912, p. 
546. 

21. Journal A. M. A., Scarlet Fever, March 13, 1915, 
908-909; March 20, 1915, 995-997; March 27, 1915, 1073-1075. 

22. Zingher, A.: Journal A. M. A., September 4, 1915, 
875-876. 

23. Reiss and Hoertz : Mdinch. med. Woch., Munich, 
August 31, Ixii, No. 35. 

24. Paoloantonio : Policlinico, Rome, November 30, 
1913, XX, No. 48, p. 1760. 

25. Jacobsen : Archives de medccine des enfants, Paris. 
April, 1914, xvii. No. 4, p. 255. 

26. Holt : T extbook. Holt and Howland, Diseases of 
Childhood. 

27. Anders : Practice of Medicine, Thirteenth Edition. 

28. Osler: Practice of Medicine. 

29. Corlett: Acute Infectious E.ranthemata, treatise. 

30. Griffith, J. P. C. : Diseases of Children, 1920, two 
vols. 

31. Nicoll, Mathias : Value of Inclusion Bodies, Re- 
search Laboratories, Department of Health, New York 
City, Archives of Pediatrics, 1913, p. 350. 

32. Fischer, Louis : Treatment of Scarlatina by Neo- 
salvarsan, Ibid, 1913, p. 352. 

33. Leopold, J. S. : Etiology of Measles, Ibid, 1913, p. 
356. 

34. Michael, May : Phenomenon of Scarlatina, Ibid. 
1912, p. 298. 

35. Miller, D. J. M. : Diagnosis of Atypical Scarlatina, 
Ibid. 1912, p. 289. 

1425 Broadway. 



The Significance of Yellow Spinal Fluid. — 

Charles H. Nammack (American Journal of the 
Medical Sciences, April, 1920) says that yellow 
.spinal fluid occurs in a wide range of diseases of 
the spinal cord and meninges. The complete 
syndrome of Froin is comparatively rare in its 
occurrence. In acute and subacute conditions the 
presence of yellow fluid strongly suggests the 
probable diagnosis of tuberculous meningitis or 
poliomyelitis. 



SEBORRHEA OF THE SCALP. 
By Charles Greene Cumstox, M. D., 

Geneva, Switzerland. 

Since premature baldness is now recognized to be 
most commonly due to seborrhea of the scalp, this 
fact has increased the interest in this morbid pro- 
cess, as well as its treatment. However, only a 
small number of dermatologists have as yet given 
special attention to this subject. In what is to follow 
I desire to call attention to the present views held 
here on the pathogenesis and pathology of seborrhea 
of the scalp, reserving ttie question of its modern 
treatment for a future communication. 

The hygiene of the scalp is to be compared with 
that of the buccal cavity and teeth. The excellent 
results obtained in the latter prove beyond question 
what can be obtained by the daily systematic care 
of the teeth. Merz, of Bale, has said that he has 
observed that often the first symptoms of seborrhea 
of the scalp coincide with the appearance of dental 
caries, therefore earlier than is generally suspected. 

At the onset, seborrhea gives rise to little anom- 
alies of the sebaceous secretion, but these are easily 
overlooked, and since for this reason the process in 
its early phase is therapeutically neglected, it con- 
tinues to progress and to develop its destructive 
action. It is, above all, these early cases of sebor- 
rhea which require urgent treatment if baldness is 
to be prevented. 

The etiology of seborrhea is at present known, 
even if opinions dif¥er somewhat on certain aspects 
of the process. Seborrhea, which is nothing but a 
sebaceous discharge, is naturally related to the pro- 
ducing organ of sebum — the sebaceous glands which 
open into the hair follicles. Therefore, this morbid 
process is not only met with on the scalp, but on all 
regions of the cutaneous surface where sebaceous 
glands exist. The hair follicle represents an epi- 
thelial invagination surrounded with numerous 
capillary vessels whose lower part bears the papilla, 
that is to say, the point where the hair forms. 

In the development of seborrhea two states can 
be distinguished which are occasioned by the ana- 
tomical construction of the follicle. Beginning at 
its starting point and continuing up to the spot 
where the sebaceous gland opens, the wall of the 
follicle retains its epithehal character. It represents 
a simple epithelial sac, while from this point up to 
the papilla it has undergone the changes and differ- 
entiation necessary for the formation of tlie 
sheaths of the root. These two parts play a very 
different part in the process of seborrhea, but if 
these simple anatomical relations in the construction 
of the follicle be kept in mind the numerous theories 
of the etiology of seborrhea may be ignored. 

The following processes are in action during the 
first phase: The epithelial duct represents an excel- 
lent receptacle for dust and filth of all kinds. The 
sebum becomes thickened by the addition of these 
foreign bodies, while its evacuation is made more 
difficult, so that by its stagnation in the duct dilata- 
tion of the latter ensues. IMerz regards this ele- 
mentary process as the onset of seborrhea. 

In this stagnant sebum decomposition is not long 
in taking place and the mechanically dilated orifice 
— the degree of the dilatation is really extraordinary 



January 22, 1921.] 



CVMSTOX: SEBORRHEA OF SCAW. 



157 



—favors the development of a rich bacterial flora 
which finds an excellent culture medium in the 
altered sebum, as well as in the favorable theramic 
conditions offered. From the development of the 
bacteria, decomposition of the sebum makes rapid 
progress, characterized by the production of organic 
fatty acids. Merz is of the opinion that the bacteria 
constantly present are a secondary factor in the 
process, but many observers are of the opinion that 
seborrhea is a parasitic process. 

Lassar has tried to show the parasitic origin of the 
disease by mixing the hair and seborrheic squams 
together in vaseline and then by repeated friction 
of this mass on the normal skin of a rabbit which 
resulted in the falling of the rabbit's hair, but 
Michelson has shown the fall of the hair and 
formation of scales can be obtained by friction with 
rancid fats without the addition of the products of 
seborrhea. 

Sabouraud, Balzer, Bizzozero and others, who 
have tried to show that certain bacteria were the 
specific agents of seborrhea, have not been much 
more successful in their attempts. The supposition 
of a specific agent has been eliminated by Scham- 
berg, who has been able to demonstrate that these 
bacteria are the usual inhabitants of the sebaceous 
glands without exercising any pathogenic action. 
Slerz believes that these bacteria have no pathogenic 
signification unless they develop in abnormally large 
numbers. This exaggerated development is made 
possible on account of the favorable preparation of 
the soil by the process which has been referred to as 
taking place in the follicle. The masses of sebum, 
decomposed and riddled with bacteria, irritate the 
walls of the follicle which, on account of the rich 
vascular supply, readily react by an inflammatory 
hyperemia. 

The immediate effect of this inflammation is an 
exaggerated production of sebum which is out- 
wardly manifested by a more abundant discharge, 
in other words, seborrhea. At this phase, the sebum 
is principally composed of yats, masses of bacteria 
and horny cells. But by degrees this condition of 
affairs changes. The horny cells become more 
numerous and are the most important of all the 
elements, and from this time on the pathological 
process has entered upon the second phase. 

Merz defines the second phase as the propagation 
of the morbid process to the deeper parts of the 
' follicle, from the opening of the sebaceous gland to 
the papilla. While the first phase may be regarded 
as a preparatory one, the extension of the process 
to the deeper structures results in serious patho- 
logical consequences. In the first place, a parakera- 
tosis and a hyperkeratosis arise in the sheaths 
surrounding the hair roots. The sheaths being the 
principal route of nutrition of the hair it can readily 
be understood that, following the process of para- 
keratosis, nutrition is made difficult and from this 
fact the papilla becomes compromised ; it will in- 
variably degenerate if the process continues for any 
length of time. 

These two states, which are pathologically differ- 
ent, have likewise a perfectly dissimilar therapeutic 
and diagnostic significance. While the primary 
-phase is relatively accessible to therapeutic agents 



and has a favorable prognosis, the second, on 
the contrary, is more resistant to medication and 
has a doubtful prognosis, especially if the affection 
has been present for some time. 

Until recently, the results of treatment for loss 
of hair have been far from satisfactory because the 
affection for a long time offers only slight svmptoms 
which are easily overlooked. Usually it is not the 
anomaly of sebaceous secretion, the abnormal drv- 
ness of the hair and scalp consequent upon the 
thickening and stagnation of the sebum in the fol- 
licle, or the increased fatty secretion which causes 
the patient to seek medical advice. The attention is 
attracted rather on account of the falling out of the 
hair which, however, may not begin until the lapse 
of several years. Consequently, treatment is not 
generally commenced until the second phase is 
reached, which has not a very favorable prognosis 
because then the organ has already become involved 
to an extent beyond repair. But, sometimes, it will 
be an acne of the face, developed simultaneously 
with the scalp affection that will bring the patient 
to the physician. 

The scalp and face are frequently involved at the 
same time, but also often one without the other. 
The single localization of the process on the scalp is 
commoner than when the face alone is affected. On 
the other hand, in the majority of cases of sebor- 
rhea of the face the same process will be found on 
the scalp. It begins at about puberty, sometimes 
quite acutely, but is more prone to assume a latent 
evolution. It would not be in conformity with facts 
to say that it never or rarely occurs before puberty, 
because when one is well versed in the subject, it is 
surprising how many cases will be found among 
children. Merz says that he has often seen cases 
of seborrhea in children from the age of five on, 
as well as instances wnere the process did not appear 
until long after puberty. He further says that he 
has never seen the acute forms in childhood, while 
they do frequently occur during and after puberty. 
Merz also classifies the cases as follows in respect 
to the age of the patient: 1, infantile seborrhea; 2, 
juvenile or puberty seborrhea, and 3, late forms. 

It is the infantile cases which have the most un- 
favorable prognosis if they are not treated in time 
and appropriately. At the age of eighteen years 
they may already cause falling out of the hair, both 
severe and lasting, and in these circumstances there 
is never any facial acne before the advent of puberty. 
These infantile forms only give rise to the most 
trifling symptoms during several years, but at 
puberty they undergo an acute aggravation. The 
patient will have then arrived at the second phase 
of the affection so that treatment then begun will 
no longer give good results. Often at this time the 
papillae are seriously affected and it is too late to 
stop the progress of degeneration. 

The symptoms of the onset of infantile seborrhea 
may merely take the form of very fine pellicles ; 
they are very adherent to the scalp and can only be 
removed by soap and brush ; or they may be fatty 
and soft, being easily detached. In spite of an 
energetic cleansing of the head, the pellicles always 
reform with a varying intensity. The formation of 
the pellicles may also cease spontaneously for a cer- 



158 



CUMSTOiX: SEBORRHEA OF SCALP. 



[New York 
Medical Journal. 



lain lime ami a cure is l)clievc(l lu have been 
attained. The use of soap and brush is a rational 
treatment as lar a> it goes, but in the majority of 
cases it is insufficient. Unquestionably, seborrhea 
may be cured bv simple warning, but this is rarely 
successful. 

It is certain thai a process of desciuamation simi- 
lar to that met with on the skin exists on the scalp 
without in any way being related to seborrhea, but 
it is impossible to distinguish macroscopically these 
two kinds of })ellic!es. As a rule, any mild pellicle 
formation in children should be regarded as a prod- 
uct of seborrhea. 

A differential diagnosis can be made microscopi- 
cally between a normal pellicle and one resulting 
from seborrhea. In the former, it is a process ot 
true keratini/.alion, that is to say, the cells of 
Malpighi's mucous body penetrate slowly through 
the stratum granulosum and become transformed 
into horny ceils by imbibition of keratohyaline and 
the loss of their nucleus. It is quite different in the 
case of a seborrheic pellicle. In this case the exten- 
sion of the cells of the mucous body towards the 
exterior takes place so rapidly that imbibition of 
keratohyaline and destruction of the nuclei cannot 
take place sufficiently, therefore the cells on the sur- 
face are incompletely horny and nucleated. Conse- 
quently, a pellicle composed of such cells is con- 
sequent upon seborrhea. 

Juvenile seborrhea — which is often accompanied 
by facial acne — has a better prognosis than the in- 
fantile form. The symptoms of the seborrhea of 
puberty are more marked ; besides, the sentiment 
of personal vanity is somewhat developed at this 
age and more attention is given to looks, especially 
to facial acne. Therefore, as these cases are treated 
earlier the therapeutic results will be more favor- 
able, but treatment must be Continued for a long 
time if a durable amelioration or cure is to be 
expected. The same may be said of the late forms 
which also have a better prognosis, in ail tnree 
forms the evolution of the affection is in a high 
degree chronic, even in cases with an acute onset. 

This formation of pellicles present in infantile 
seborrhea and also in a similar way in other forms, 
may last for years, without any visible destruction 
of the hair being observed. The falling out of the 
hair commences gradually. Some hairs will be 
found on the brush ; in the morning some will be 
found on the pillow and the increase of the loss of 
hair takes place so slowly that it is overlooked. 
Now, although these early symi)toms may seem to 
be insignificant for some time, they nevertheless 
show that the second phase has begun to injure the 
papillai and that treatment is absolutely urgent. This 
warning is frequently not observed, and it is only 
.some time after that, in addition to falling out, the 
character of the hair itself changes. It becomes 
dull, loses its normal turgescence and often lies flat 
on the head soon after it leaves the follicle, giving 
the impression that it is withered. Besides, it does 
not grow long. The ])oints are bifid and look as 
if cru.shed or fringed. 

All this signifies that there are .serious disturb- 
ances of the nutrition, most usually the conse(|uence 
of advanced morbid changes in the papilla, therefore 



the prognosis is bad. 1 he hair is lost and treatment 
must then be confined to saving the hair the least 
involved, because the morbid process does not 
develop equally all over the scalp and lying beside 
hairs that are beyond recovery others will be found 
less severely involved. In the cases where the 
sheaths of the root show only little parakeratosis 
and in which the papilla is little, if at all, involved, 
proper treatment may be successful, but in the more 
advanced cases the affection continues its progress. 
I'he stratum granulosum gradually disappears and 
the skin atrophies. The sudoriparous glands are 
degenerated, the sebaceous glands and muscular 
fasciculi disappear, while the connective tissue and 
elastic fibres increase. The skin having become 
bald is smooth and brilliant. 

Microsco]Mcally, hairs dead from seborrhea can- 
not be distinguished from those which have fallen 
out naturally. They have an onion shaped root 
ending in a point and so far as can be seen are nor- 
mal in their other characters. One think that is re- 
markable is the stability of the localization of bald- 
ness which occurs only on certain fixed parts of the 
seal]), while in other regions seborrheic alopecia 
never occurs. Many theories have been given to 
explain this fact. Elliott is of the opinion that those 
portions of the scalp lying upon muscles are never the 
seat of the process under consideration. He thinks 
that the play of the muscles favors the transporta- 
tion of the blood and lymph to the parts situated 
above. Schem maintains that the food supply 
brought for the other parts which are situated 
directly on the aponeurotic galea is made difficult 
by the tension of the occipital and frontal muscles. 

Merz considers that an une(|ual size of the orifice 
of the follicle is also a predisposing factor. One 
often meets, even when .sebaceous stasis is not yet 
marked, very large openings far from the hair, so 
that the latter is no longer within its sheath but in 
a funnel, which favors the entrance of dust, bac- 
teria, etc. This predisposing factor may explain 
why baldness is hereditary. These large orifices of 
the follicles are individual conditions which may 
be transmitted from one generation to another and 
therefore constitute an hereditary disposition which 
favors the develoiMiient of seborrhea. This is there- 
fore a strict indication for the resort to proper jiro- 
])hylactic treatment of the scalp from childhood. 
1 here append a classification given by Merz, which 
sums up the different phases of seborrhea of the 
scalp up to the time that baldness has been reached : 

FIRST PII.VSE. 

1. Hereditary ])redisposition to seborrhea possible. 
2. Penetration of dust, bacteria, etc., within the 
follicle. 3. Thickening of the sebum. 4. Mechan- 
ical dilatation of the follicular sac ; excessive bac- 
terial develojMiient ; decomposition of the sebum. 
5. Inflammatory reaction of the walls of the hair 
follicle. 

SECCJ.XD PH.\SE. 

1. l-lxtension of the inflammation to the deep jjarts 
of the follicle. 2. Hyperkeratosis and parakera- 
tosis of the sheaths of the root of the hair. 3. Dis- 
turbances of the nutrition of the hair. 4. Degenera- 
tion of the papilUe. 5. Atrophy of the skin. 



January 22, 1921.1 



LONDON LETTER. 



159 



LONDON IJ^TTER. 
(From our owii corrcsj^ondcnt .) 
Women ill the Medieal I'rofessiun — /'r/ri' /;/ Ophlhalmology. 

LoNi)t)X, January j, jg2i. 

The rii.^h of candidates for admission to the 
medical scliools of Cireat Britain is so ^reat as to 
be eml)arrassing to those responsible for the manage- 
ment of such schools. The schools which admit 
women as well as men are presented with an inter- 
esting" problem. This new factor of the situation 
was largely created l)y the wartime experiment of 
admitting women to medicine at several of the 
schools, on account of the number of medical men 
who were called to service under the colors. The 
men have now returned, but find that the women 
have come to stay. How is the problem to be faced 
by those institutions which allow female medical 
students within their. walls? Are the women to be 
denied admission in the future, or are the vacancies 
to be divided, and, if so, in what proportion? It 
is said that the authorities are at the present 
endeavoring to evolve a definite .scheme whereby 
exservice men will i)robably receive preferential 
consideration, but the settlement as concerns the rest 
is a more difficult and delicate matter by far. 

Up to the time of the war women medical students 
were almo.st wholly concentrated in the Royal Free 
Hospital School for Women in London. After a 
good deal of discussion and some controversy it 
was resolved in 1917 to open the doors to women 
more generally, and the medical schools of Univer- 
sity College Hospital, King's College Hospital, Lon- 
•don Hospital, Charing Cross, Westminster, and St. 
Mary's hospitals, all of London, have taken in 
-woman students. St. George's Hospital, London, 
did the same purely as a war measure, and has now 
again closed its doors to women. The Middlesex, 
Bartholomew and Guy's hospitals, London, have 
■consistently and firmly refused to admit women. 

An important reason why the problem is so hard 
to solve is that women are proving themselves apt 
pupils in the profession of medicine or surgery. 
The experience of the past few years has taught the 
lesson that not only is there a definite scope for 
women doctors in the fields of child welfare, public 
health work, and so on, but even in the practice of 
■medicine generally. It has been estimated recently 
that if the total number of medical students in Great 
Britain now studying for their degrees or qualifica- 
tions pass successfully, that women doctors will 
■represent five per cent, of the total supply. More- 
over, this percentage will increase rapidly, taking 
into consideration the fact that adoption of medi- 
cine by. women is a development of comparatively 
■recent times. 

It is evident that in Great Britain, at any rate, 
women are now entering the medical profession in 
the same way and for the same reasons as men do, 
for the sake of earning a livelihood in a calling for 
which they have a liking and an aptitude, and the 
prejudice which existed against women doctors is 
■dying out mainly because they have shown them- 
selves to be fitted for the work. At many of the 
London hospitals there are both men and women 
resident medical officers on duty, women patients 



assigned to women doctors, men patients and vio- 
lent cases to men doctors. Of course, at the Royal 
Free Hospital, London, which is the women's med- 
ical school, almost all the resident officers are women, 
and it is the usual thing for the women on duty 
to deal with all and any cases that come in. The 
task naturally often involves a considerable amount 
of ])hysical endurance, and much surgical and med- 
ical skill and judgment. It has been established 
beyond cavil that women are ([uite competent to 
undertake such duties. At the Royal Free Ho.spital 
there are 450 women medical students, ninety-five 
of whom are new this session, although the lists are 
not complete. 

Jt will be observed, then, that the (|uesti()n of 
wonien medical practitioners in (ireat Britain has 
become one of general importance. CJwing to the 
lack of accommodation in the British medical 
schools, and the large number of students to enter, 
the schools have a (Hfficult problem to solve in try- 
ing to reconcile the claims of men and women, re- 
spectively. However, it is certain that a feeling is 
growing that it is no longer possible to revert to 
l^rewar conditions in this direction. 

In America women have not progres.s'ed so far 
along the.se lines as in Great Britain, but this phase 
of the feminist movement will assuredly develop. 
It is impossible to speak dogmatically on the sub- 
ject, but it may be said that in certain branches of 
medicine and, perhaps, of surgery, women will find 
a jilace and be able to hold it. For child welfare 
work and for public health affairs they are pecu- 
liarly well adapted, and in many cases they are better 
fitted to attend members of their own sex than men. 
Indeed, there is no gainsaying the statement that 
women iiave demonstrated that they make capable 
medical ]:)ractitioners, and that there are many med- 
ical i^ositions which they are excellently qualified 
to fill. * * * 

Mr. W. Edmonds and Miss S. Edmonds, of 
Wiscombe Park, Colyton, have founded a prize in 
ophthalmology in memory of their brother, Nicholas 
Giff'ord Edmonds, who fell at Magersfontein on 
December 11, 1899. The prize, of the value of 
ilOO, will be awarded every two years for the best 
essay on a subject dealing with ophthalmology and 
involving original work. The competition is open 
to all British subjects holding a medical c|ualification. 
Subject to certain legal conditions, the management 
of the prize will be in the hands of a committee 
nominated biennially by the Medical Board of the 
Royal London Ophthalmic Hospital, which will 
select the subject of the essay and elect two exam- 
iners. The winner of the prize will have the option 
of giving a lecture on the subject at the Royal Lon- 
don Ophthalmic Hospital. As the subject of the 
essay will be announced two years before the award, 
ample time will be afforded for studying the litera- 
ture, for thorough observation, and for carrying out 
experiments before sitting down to the actual com- 
position of the essay. By their generous liberality 
Mr. and Miss Edmonds place the profession under 
a deep debt ; their wish in founding the prize 
is that suffering may be alleviated, and it may 
be confidently anticipated that this end will be 
attained. 



Editorial Notes and Comments 



NEW YORK MEDICAL JOURNAL 

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NEW YORK, SATURDAY, JANUARY 22, 1921. 



MAN VERSUS THE MICROBE. 

There appears to be a reaction on the part of the 
medical profes.sion against the dominance of the 
microbe. It has been the custom to attribute the 
occurrence of an epidemic of contagious disease to 
a certain microbe. For instance, when PfeitYer 
isolated a germ during the epidemic of influenza in 
1889 and succeeding years, it was widely proclaimed 
and is given in textbooks of medicine and in medi- 
cal dictionaries, as the specific cause of influenza. 
Some hold the view that it is not the specific germ 
at all, while others aver that it is only one of the 
microorganisms concerned in the production and 
development of influenza. Sir William J. Collins 
in the Lancet for December 11, 1920, discusses this 
question in an illuminating manner. So far back 
as 1889 he said: "If it be true that in the life 
history of the lowest of organic things lie the 
momentous influences which determine plagues and 
pestilences, it is reasonable to believe that in organ- 
isms whose cycle may be less than an hour, and 
whose rate of propagation is incalculable, evolution 
must be powerfully at work eventuating in the sur- 
vival of those most fitted to their environment, and 
that in this, as in other directions, man's influence 
may modify natural selection and by acting in 
accordance with law may learn to conquer nature 
by submitting to her." In short, it is stated that we 
have been likely to regard microorganisms too much 
in the light of their fortuitous and unfortunate asso- 
ciation with diseases of man and too little in the 
light of their own life hi.story. 

In spite of what appears to be strong evidence 



against the absolute specificity theory of di-sease 
practically all textbooks of medicine state explicitly 
or infer that such is the case. Collins describes 
the orthodox credo as running somewhat as 
follows : "I believe that diseases, especially those 
which are communicable, are due each to a specific 
microbe, which is always derived from a preexist- 
ing similar organism in a previous case of disease. 
That such specific diseases always breed true and 
never arise dc novo. That immunity from attack 
can only ha purchased by preventive inoculation 
either with the specific organism alive or dead or 
with a serum charged with a specific antitoxin 
derived therefrom." , 

On the other hand, Collins has long contended 
that specificity of diseases is relatively not absolute ; 
that new species have evolved from time to 
time ; that starting from common infective agency 
by variation and mutual selection specific diversities 
of type may emerge, and that, instead of always 
breeding true, aberrant and typical exainples and 
nondescripts are commonly observed. That the 
condition of the blood and tissues of the body ex- 
posed to socalled zymotic or infective disease power- 
fully influences the virus of the disease to the extent 
of modifying, intensifying or nullifying the morbid 
process as soil influences the growth and results of 
the seed sown upon it. That the environment of the 
body also potentially affect its vulnerability or im- 
munity from disease. That if the nature of the 
inatcries morbi of specific infective diseases be or- 
ganic or microbic, such lowly organisms as have been 
casually associated with certain diseases are likely to 
be profoundly influenced by the soil upon which they 
are cultivated and are therefore peculiarly suscep- 
tible to evolutionary changes in the course of their 
rapid propagation and multiplication. That the 
pathogenetic properties of such organisms or 
viruses may be acquired, lost, modified, or varied 
during their serial cultivation in living bodies or in 
other culture media. 

Seeing that the pos.sible modes of reaction of the 
living body to noxious agencies or influences are 
limited in number and nature, similar or identical 
symptoms may be occasioned by dififerent patho- 
genetic causes ; while the same pathogenetic agencies 
may occasion dififerent symptoms in dififerent per- 
sons. That the first line of defence against invasion 
of the human body by infective diseases is a sanitary 
environment, pure air and water, good food, clean 
clothes and houses and that such environment pro- 
motes healthy living, which itself tends to raise the 
normal resisting powers of the body and the blood. 



January 22, 1921.] 



EDITORIAL ARTICLES. 



161 



So many things have to be taken into account in the 
evolution and development of disease, that it is 
difficult to believe in the hard and fast specificity of 
microorganisms or, at any rate, of all. \\'hen bac- 
teriology has not succeeded in demonstrating 
microbic catises in some of the most typical infective 
diseases, of which perhaps influenza may be cited 
as an example, it causes one to think and ponder. 
Some are veering to the belief that contagion may be 
in the nature of a chemical process. 

Undoubtedly chemicophysics is throwing a bright 
light upon many dark and obscure nooks and cor- 
ners and may in time revolutionize present day 
views as to the causation of infective disease. In 
any event, the absolute specificity theory of disease 
is being subjected to a good deal of criticism, some 
of which reads as if it were destructive and it seems 
as if an open mind is required by those who are 
delving into the secrets of disease. Such men 
should not be bound down by preconceived views 
or trammelled by favorite hypotheses but should be 
ready and willing, in the interests of science and 
humanity, to listen to any suggestions or advice 
which may seem likely to blaze a fresh trail, and to 
jttdge for themselves whether they are following a 
will o' the wisp or are on the high road to new dis- 
coveries. With regard to CoUins's statement that 
healthy environment, nourishing food and so on, 
go a long way towards rendering the body resistant 
to the attacks of disease, opinion is unanimous. 
Living under healthy conditions is a sine qua non in 
the practice of preventive medicine. It is indeed 
the keystone of health. 



THE PROBLEM OF THE REGISTERED 
XURSE. 

The Chautattqua School of Nursing has appealed 
to the courts for protection for its graduates. A 
Supreme Court injunction has been issued, restrain- 
ing the New York State Nurses' Association and 
the secretary of the New York State Board of 
Nurse Examiners from continuing to circulate any 
statement designed to create the belief that gradu- 
ates of the school will be prohibited by the laws of 
the State of New York from practising nursing for 
hire, or that such graduates, or all professional 
nurses, must procure a certificate from the Regents 
of the State of New York. 

The organized hospital trained nurses' associa- 
tions have attempte^l to monopolize the nursing 
field. There are not enough hospital trained nurses 
to supply the needs of the community, and many 
of the sick and disabled are unable to pay the fees 
of these nurses. Must they do without nurses? 
Graduates from the Chautauqua school have sup- 



plied this need for many years. During the influ- 
enza epidemic the scarcity of nurses was the direct 
cause of many fatalities. During the war the 
greatest aid was furnished in the military hospitISs 
by the auxiliary nurses. They were efficient after 
a few months' training, and their work saved thou- 
sands of Hves. 

Nurses graduated from the Chautauqua school 
fill an important need. There is no reason why 
the hospital nurses should fight them. There is no 
reason why they cannot work together in harmony, 
for the nurses of the school extend their services 
into many fields which the hospital nurses will not 
enter. There is plenty of work for all. There is 
no need to attempt a monopoly in a field of en- 
deavor whose purpose is the good of sick mankind. 
The immediate financial gain should not blind the 
hospital nurses to the greater gain of health to 
individuals and to the community. 

PHYSICIAN AUTHORS: DR. VIKENTY 
VERESAEV. 
One of the foremost Russian intellectuals who 
paved the way for the overthrow of the house of 
Romanoff was Vikenty Smidovitch, a physician 
who wrote under the pen name of \'ikenty Vere- 
saev. Students of the causes which led up to the 
Revolution of 1917 declare his stories did more 
than the writings of any other author to put the 
Russian masses into the mood for striking against 
czarism, and to show them how to consolidate 
effectively for such a step. He was the guide, phi- 
losopller and friend of all the revolutionary groups 
of Russia during the years of their preparation for 
the big stroke that was to come. His writings, first 
to last, were sheer propaganda in fiction form. 
Every character in his stories, every incident, had 
for its purpose the driving home of the hard and 
bitter facts of life in old Russia. He did not care 
whether he amused or pleased, so long as he in- 
flamed and instructed. S. Persky, in his Contempo- 
rary Russian Novelists, a prewar volume, points 
out that Veresaev "brought" into the world of 
literattire a series of characters who summed up the 
rising fermentation of new ideas and seemed to be 
the spokesman of those around whom the Russian 
revolutionary forces gathered, forces which up to 
that time had been scattered. He was I)oni," con- 
tinues Persky, "in the midst of the revolutionary 
movement and its ideas were an integral part of 
him. He was able to present its political opinions 
in such a way that their effect was tremendous. He 
described how the ground was being cleared for 
revolution and what shotild be done further to pave 
the way." 



162 



EDI TORIAL ARTICLES. 



[New York 
Medical Journal. 



Veresaev is scarcely known outside his native 
country, but within that country his fame at one 
time overshadowed even that of such geniuses as 
Chekov and Gorky. His books answered a more 
general need than theirs. Most likely he never will 
be known widely outside of Russia, for his fiction 
is said to be a commonplace product. As an author 
he never was more than a second rater, and was 
read more for his political opinions than for his 
literary talent. "Each page of him was written to 
throw light on social questions, considered from a 
well defined point of view. The secret of his 
success" — again it is Persky who speaks — "rests 
mostly in the frank, sincere manner in which he 
approached certain problems of vital interest to the 
mass of Russians." Furthermore, he expresses a 
deep and tender sympathy for those who suffer and 
always is journalistically accurate in describing 
what he has seen and lived through. 

Outside of Russia he is best known for his 
Memoirs of a Physician. This was his masterpiece, 
the cream of his literary output, despite the popu- 
larity in Russia of his novels and tales, and has been 
translated into practically all languages. These 
memoirs, the confessions of a doctor from the time 
of his earliest studies, deal with the many dishearten- 
ing problems which confronted physicians in Russia 
a quarter of a century ago. In school he learns with 
astonishment of the vast number of maladies that 
afflict mankind, and is further astonished by the 
fact that medicine is unable to cure many of those 
maladies. Later he gives his observations in hos- 
pitals and other practice, and comes to the general 
conclusion that the first step toward rectifying the 
evils should be a change in the social organism. 

"He views his profession with the eyes of a man 
discouraged and disheartened," says Dr. Henry 
Pleasants, Jr., "and shows us a conscience harassed 
and troubled by conditions he feels powerless to 
improve, leaving the reader floundering in a bog of 
hopeless pessimism. The book made many enemies 
by its frankness and angered those whose best in- 
terests were served in concealing the truth, but it 
shows how earnestly and faithfully physicians have 
endeavored to prove worthy of the trust imposed 
upon them." 

It is only necessary to read the Memoirs to per- 
ceive the moral relation between Veresaev and the 
heroes of his stories. The medical profession never 
moulded the form and context of any writer of 
general literature more than it did his. His medical 
practice gave him the background for not only some 
but all of his stories. "There is not a single book 
that might not be a confession," says one critic, "for 
all he writes he has experienced himself." Dis- 



ease and its ravages till many of his pages. Misery, 
despair and crime are constantly portrayed. The 
poverty of the villages is painted in depressing col- 
ors. He is perhaps the gloomiest of all Russian 
writers. 

Dr. Veresaev was the son of a Polish physician 
and Russian mother. He was born in Tula in 1867 
and ten years later entered the local school, where 
he spent seven years. In 1884 he enrolled in the 
department of historical sciences at the University 
of Petrograd and got the degree of letters four 
years later. He then entered the University of 
Zhuriev ( historic Dorpat) and began his medical 
studies. He got his degree six years later. Two 
years prior to that, however, in 1892, he served as 
a physician's assistant in an eastern province during 
a cholera epidemic and also did similar service in a 
mining district, where he saw a peasant revolt in 
which several physicians were killed and others 
burned by the mob. He has traced these sad 
events in his first story. Astray, published in 1896. 
This story brought him immediate fame and was 
followed by a series of stories dealing with peasant 
and factory life, and outlining the various phases of 
the revolutionary movement between 1880 and 1890. 

His theory was that peasants could better their 
position only by getting rid of the land in order to 
become free proletarians. He represents the peas- 
ant as full of infinite egoism, without any spirit of 
solidarity, sacrificing everything for the love of his 
sorry little house and his morsel of ground, which 
was insufficient to nourish him. Veresaev's first 
medical practice was in his native city, Tula, after 
which he became a house surgeon in the Botkin 
Hospital in Petrograd, where he served seven years, 
until 1901, when he was expelled from Petrograd 
and Moscow because he had been one of the signers 
of a petition protesting against the brutal attitude 
of the police during a student demonstration. 
Thereafter he lived successively in Italy, Germany 
and Switzerland, where he practised his profession 
among the colony of Russian jwlitical exiles at 
Geneva. During the Russo-Japanese war he served 
as a surgeon in the Manchurian campaign and his 
story. III ihc War, details his experiences in the 
moving hospitals and the terrible sufferings of the 
Russian muzhiks. 



THI-: REASON WHY. 
All drug addicts can give a reason for beginning, 
one quite satisfactory to themselves, but they rarely 
furnish one for leaving off. Some, like Professor 
Wood, of ICdinburgh, say frankly: "I take it, sir, 
because I am a hedonist." Wilkie Collins took it 
twice a day for twenty years, saying it stimulated 



January 22, 1921.] 



EDITORIAL ARTICLES. 



163 



his brain and steadied his nerves. Bulwer Lytton 
gave the same reason. Rossetti's young wife began 
to take it for nervous exhaustion, and Rossetti him- 
self, greatly pleased with "the newly found drug, 
chloral," began with ten grains and finally ruined 
his health. One most amusing incident as to 
reasons happened with Coleridge and De Quincy. 
The first said he had to lake it for rheumatism, and 
wrote expostulatory letters to the latter, urging him 
to give it up. De Ouincy was angry, and said: 
"I have told the reader most truly that not any 
search after pleasure, but mere extremity of pain 
from rheumatic toothache drove me in the use of 
opium. Coleridge had simple rheumaUMU. Mine, 
which raged for ten years, was rheumatism in the 
face, combined with toothache. This I inherited 
from my father." He wrote to Coleridge, saying 
that simple rheumatism was not sufficient reason, 
but, with toothache added, any man had enough 
excuse, for there was no pain so acute. It was 
often underestimated because it had never ended 
fatally and often ceased suddenly. De Qtiincy was 
unacquainted with what the modern dentist sees in 
that wicked tooth which has its own way in a 
germ laden mouth. 



OPTICAL ABUSES. 

It is an old and approved motto in medicine that 
any therapeutic procedure should at least not do 
harm. Such a rule does not seem to "overn manv 
opticians, though in their practice if they do not do 
good they are quite likely to injure. There has 
come to our attention, within a few months, the 
following cases: A student had sufifered from head- 
aches since having his lenses broken and replaced. 
Examination showed that the lens for the right eye 
had been placed in front of the left eye. and that 
for the left in front of the right. The removal of 
the glasses, which were little needed, cured the head- 
aches. A young lady wearing glasses was, in the 
course of a routine examination, tested for vision, 
which was found to be normal. The glasses were 
not lenses, but of plain glass, and were fitted 
"because her pupils were too large." A boy of 
twelve with marked stral^ismus was found with 
similar glasses fitted at high co.st to "cure" the 
crossed eyes. A middleaged woman was having 
much trouble with her/iiew bifocals. She could not 
use them for near work without great discomfort. 
Examination revealed that the nosepiece was so 
wide as to throw the lenses for near work out of 
line of vision. 

A routine examination of a hundred people, in 
some parts of the country at least, will show many 
sufferers from the work of ignorant or unscrupulous 



glass fitters. A large number of school children are 
the worse for carelessness in prescribing and in 
fitting of glasses, and many are wearing glasses years 
after they have outgrown them. On this account, 
if for no other, there is need of more prophylaxis 
in schools. In .spite of the fact that medical inspec- 
tion tinds fewer cases of imperfect vision now 
than formerly, there are more defects found in 
children of higher than of lower grades. Many 
schools are still badly lighted and much night study 
is urged. It is evident that adult patients who wear 
glasses, as well as those who do not, should be 
examined bv the ])iiysician to whom they come lor 
ills referable to eyestrain, to learn whether their 
glasses are appropriate. Above all, tiie conscience- 
less fitter of glasses needs to be further scjuelclied 
in his work liy public measures. As a penalty for 
his misdemeanors he might apjiropriately be pun- 
ished by being made to wear misfitted glasses. The 
eye is too delicate and too important an instru- 
ment to receive other than the best of treatment. 

A UNIQUE CASE. 
It is often urged as consolation in sickness or 
other trouble, that there are dozens, thousands, 
equally or even more afflicted in a similar way. 
The nature of an invalid is well seen by the way 
this consolation is taken. He may cheerfully enter 
into the community of suffering if unavoidable. 
He may be plunged into deeper dejection because 
sorrow and disease are so common. He may deeply 
resent his claim to being a unique case disputed, 
because he morbidly enjoys the distinction of being 
more diseased than others. Watch the egocentric 
dilating on his case to friends: every detail is dwelt 
on, particularly the interest of the doctors ! A 
sympathetic listener will tell of one who had pre- 
cisely the same symptoms, even worse. The face of 
the first si)eaker falls. He gives an incredulous 
sniff and raises his eyebrows. He is annoyed and 
relapses into silence. It is the same with a chronic 
invalid if she is put in the shade bv someone in 
the family being taken ill. She will even cry, pre- 
tending her tears are those of sorrow for the invalid, 
whereas they are drawn by jealousy, and perhaps 
stay in bed in case relatives should assume she is 
able to help. Such ])atients are the despair n{ 
every doctor, because they are afraid that ctire 
would deprive them of the additional notice and 
care tliey so thoroughly enjoy, while secretly doing 
their best to avoid health. Pretending to grave 
symptoms seems to them such a nice, lazy way of 
gaining notoriety, because they can always get a 
reputation for unselfishness by saying how they 
would love to help if their health permitted. 



164 



NEWS ITEMS. 



[New York 
Medical Journal. 



News Items. 



Personal. — Dr. Alfred Gordon, of Philadelphia, 
has been elected a member of the Neurological So- 
ciety of Paris, France. 

Damages for Blindness Due to Wood Alcohol. 

—A verdict of $30,000 damages was returned in the 
Circuit Court of Chicago on January 14th in favor 
of the plaintiff, who was made blind by drinking 
wood alcohol. 

Spanish Medical Journal Changes Name. — An- 
nouncement is made by the publishers that the 
Reznsta dc Mcdicina y Cirugia Prdcticas, a monthly 
periodical published in Madrid, has changed its 
name to Archivos dc Medicina, Cirugia Espcciali- 
dadcs. 

Hospital for Criminal Insane in Baltimore. — 

The State Lunacy Commission has submitted to the 
Board of Public Works plans for the construction 
of a hopsital for the criminal insane. For the build- 
ing of such an institution $100,000 has been pro- 
vided in the public improvement loan of $1,500,000. 

Historical Medicine. — The Section in Histor- 
ical Medicine of the New York Academy of Medi- 
cine will hold its next meeting on Monday afternoon, 
January 31st. at 5 o'clock. Dr. Walter Eyre Lam- 
bert will present a History of the New York Eye 
and. Ear Infirmary, and an open discussion will 
follow on the development of ophthalmology in New 
York city. 

Harvey Society Lectures. — The sixth lecture 
in the series will be given Saturday evening, Jan- 
uary 29th, at 8:30 o'clock, at the New York Aca- 
demy of Medicine, by Sir Arthur Newsholme, 
resident lecturer in charge of Public Health Ad- 
ministration, School of Hygiene and Public Health, 
Johns Hopkins University. His subject will be 
National Changes in Health and Longevity. 

Brooklyn Cardiological Society. — The second 
meeting of this society will be held Monday evening, 
January 31st, at 8:30 o'clock at the residence of the 
president. Dr. William J. Cruikshank, 102 Fort 
Greene Place, Brooklyn. The paper of the evening 
will be read by Dr. Harold E. B. Pardee, of Man- 
hattan, his subject being the Field of Usefulness 
of Polygraph and Electrocardiograph in the Diag- 
nosis of Cardiac Disease. 

Reception to Dr. Keen. — On Thursday even- 
ing, January 20th, a dinner followed by a reception 
was given in honor of Dr. William W. Keen at the 
Bellevue-Stratford Hotel, Philadelphia, by his medi- 
cal colleagues. Dr. George E. de Schweinitz acted 
as toastmaster and among the speakers were Dr. 
Faunce. of Brown University; Dr. J. Chalmers da 
Costa, Hon. David J. Hill, 'and Dr. William H. 
Welch, of Johns Hopkins Lmiversity. 

Reports from State Hospitals Show Increase in 
Alcoholism. — Dr. Menas S. Gregory, of the 
psychopathic department of Bellevue Hospital, is 
credited in the public press with the statement that 
a study of reports from state hospitals shows that 
serious cases of alcoholism are on the increase and 
that there has been a startling number of cases of 
insanity resulting from what has been called whis- 
key madness. Dr. (jregory is reported as saying 
lliat alcoholism has increased here 100 per cent. 



Bronx Hospital. — At the last meeting of the 
Medical Board of the Bronx Hospital and Dispen- 
sary, Dr. W. J. Robinson and Dr. Martin Rehling 
were reelected president and secretary respectively. 

Hospital for Joint Diseases. — At a special 
meeting held on November 14, 1920, the board of 
managers of the Hospital for Deformities and Joint 
diseases, situated at 1919 Madison Avenue, New 
York, passed a resolution recommending changing 
the name of the corporation to the Hospital for 
Joint Diseases. The necessary papers were filed 
with the Secretary of State and the use of the new 
name was authorized from December 1st. 

Norwegian Lutheran Hospital Approved by 
College of Surgeons.— At a "smoker" given on 
January 10th to the medical staff of the Norwegian 
Lutheran Deaconess's Home and Hospital, Brook- 
lyn, by the board of managers, a letter was read 
by Dr. John C. Bowman, of the College of Sur- 
geons of North America, stating that this institution 
would appear in the final list of approved hospitals. 
President Larsen occupied the chair and spoke for 
the institution, and addresses were delivered by Dr. 
Robert E. Coughlin, Dr. Lewis S. Pilcher, and Dr. 
H. Beeckman Delatour. 

Cancer Committee Formed in Cincinnati. — An 
organization known as the Divisional Council on 
Cancer Control was launched in Cincinnati on 
November 4, 1920, under the joint auspices of 
the City Health Department, the Academy of Medi- , 
cine, and the Public Health Federation, for the 
purpose of carrying on an intensive educational 
campaign in the city of Cincinnati. Dr. J. Louis 
Ransohoff is chairman of the committee and among 
its members are Dr. William H. Peters, Dr. Nora 
Crotty, Dr. Louis Schwab, Dr. Dudley W. Palmer, 
Dr. Mark A. Brown, Dr. Robert Carothers, Dr. 
Julien E. Benjamin, and Dr. Thomas P. Hart. 

Association of Cardiac Clinics. — A meeting of 
this association was held Wednesday evening, Jan- 
uary 26th, at the New York Academy of Medicine. 
Dr. May G. Wilson presented a paper on the Equi- 
valent of Ordinary Exertion ; Dr. Joseph H. Barach, 
of Pittsburgh, read a paper on Etiology of Cardio- 
vascular Affections, and Dr. Paul D. White, of the 
Massachusetts General Hospital, Boston, read a 
paper on the Diagnosis of Chronic Valvular Disease. 
Among those who took part in the discussion were 
Dr. Lewis A. Connor, Dr. Alexander Lambert, Dr. 
E. Libman, Dr. Theodore B. Barringer, Jr., and 
Dr. B. S. Oppenheimer. 

Medical Society of the County of New York. — 
A stated meeting of this society will be held in 
Hosack Hall of the New York Academy of Medi- 
cine, on Monday, January 24, 1921. The program 
will consist of the inaugural address of the presi- 
dent. Dr. George Gray Ward, Jr., and the following- 
papers : Severe Rachitic Involvements of the Tho- 
rax and Certain of Their Consequences, by Dr. 
Edwards A. Park and Dr. John Howland, of Johns 
Hopkins Hospital, and the Treatment of Rickets. 
Especially the Results Accomplished by Means of 
Codliver Oil, with a lantern slide demonstration, 
by Dr. John Howland. Among those who will take 
part in the discussion are: Dr. Alfred F. Hess, Dr. 
Oscar M. Schloss, and Dr. Walter Lester Carr. 



Jiiiiuary 22, 1921.] 



XEIVS ITEMS. 



165 



Hiccough Epidemic Alarms London. — The epi- 
demic of hiccoughs is spreading through London, 
and the medical profession is taking a serious view 
of its progress. There are twelve cases in one hos- 
pital. Some of the victims are on the verge of col- 
lapse after constant hiccoughing for days. No 
medical explanation of its cause has been given. 

American Society for the Control of Cancer. — ■ 
The annual meeting of the society will be held at 
the Executive Office, 25 West Forty-fifth Street, 
New York, Saturda\- afternoon, January 29th, at 
four o'clock. The chief business will be the elec- 
tion of officers for the coming year, receiving the 
report of the Budget Committee, and the election 
of directors to fill vacancies of those whose terms 
have expired. 

No Appropriation for Long Island Hospital for 
Disabled Soldiers. — The plan for a $3,000,000 hos- 
pital for disabled soldiers on the Creedmoor site in 
Queens has been killed by the U. S. Senate Com- 
mittee on Appropriations. The original plan was 
to build the hospital for State appropriation and the 
Federal Government to lease it, paying instalments 
enough to cover the entire cost of the project and 
then turn the hospital back to the State. 

Shortage of Nurses in New York. — So great is 
the dearth of nurses in several of the New York 
City hospitals that the New York County Chapter 
of the Red Cross has been asked to send out a gen- 
eral call for volunteers to act as nurses' aids and re- 
lieve the situation. 

The institutions hardest hit are the Metropolitan 
Hospital and the City Hospital on Blackwell's 
Island and the Public Health Service Hospital at 
Fox Hills, S. I., which is crowded with ex-service 
men, for the most part chronic cases. The Red 
Cross estimates that it can place as many as 500 
women . 

Damages for Prenatal Injury. — The Appellate 
Division of the New York Supreme Court, by a 
vote of three to two, decided recently that a child 
is entitled to recover damages for a prenatal injury. 
The court heard a suit in behalf of an infant, against 
the owner of property, because the child's mother 
had fallen through an open coal hole in the sidewalk 
just before the birth of the child, which caused 
permanent prenatal injuries to the infant. 

Justice Merrell, writing the prevailing opinion, 
ruled that the rights of human beings do not neces- 
sarily originate at birth, but in many cases precede 
birth in their origin. 

Board of Health Demands Registration of Pat- 
ent Medicines. — At a meeting of the Board of 
Health of the Department of Health of the City 
of New York, held on AYednesday, December 29th, 
resolutions were adopted governing the registration 
of patent and proprietary medicines and recom- 
mending the amendment of Section 117 of the 
Sanitary Code. According to these regulations, 
manufacturers must file statement of quantity of 
scheduled drugs and no proprietary preparations 
containing harmful drugs can be registered. All 
applications for a certificate of registration shall be 
made upon official application blanks supplied by 
the health department and signed by the applicant. 
Once a month a list of registered proprietary and 
patent medicines will be published by the department. 



New Million Dollar Building for Peoples Hos- 
pital. — The Peoples Hospital, now situated at 203 
Second Avenue, has purchased as a site for a new 
million dollar hospital 222 to 232 East Fifteenth 
Street. The property which was purchased from 
various owners consists of five four and five story 
old fashioned private dwellings having a frontage 
of 116 feet on the south side of Fifteenth Street. 
It is hoped that twenty stories may be permitted, 
though there is some fear that the zoning ordinance 
may restrict the structure to fourteen. Accommo- 
dations will be provided for 500 patients. Every 
modern hospital develojimcnt will be included in tiie 
new home. The work of demolishing the old build- 
ings on the site will begin, it is planned, in six 
months. Probably two years will be consumed in 
completing the new building for occupancy. After 
that time the present hospital will be used as a dis- 
pensary. 

Meetings of Local Medical Societies. — The fol- 
lowing medical societies will meet in New York 
during the coming week : 

Tuesday, January 25th. — New York Academy of Medi- 
cine (Section in Obstetrics and Gynecology) ; New York 
Dermatological Society ; New York Medical Union ; 
Metropolitan Medical Society of New York City; New 
York Otological Society ; New York Psychoanalytical So- 
ciety ; New York City Riverside Practitioners' Society 
(annual) ; Therapeutic Club (annual) ; Valentine Mott 
Society; Washington Heights Medical Society; Clinical 
Society of the Hospital and Dispensary for Deformities 
and Joint Diseases. 

Wednesday, January 26th. — New York Academy of 
Medicine (Section in Laryngology and Rhinology) ; New 
York Society- of Internal Medicine ; New York Surgical 
Society ; Brooklyn Pediatric Society. 

Thursday, January 27th. — Hospital Graduates' Club of 
New York (annual) ; New York Physicians' Association ; 
Ex-Intern Society of the Methodist Episcopal Hospital, 
Brooklyn. 

Friday, January 28th. — Academy of Pathological Science : 
Audubon Medical Society (annual) ; New York Clinical 
Society ; Society of Alumni of Sloane Hospital for WomeiTT 
Brooklyn Society of Internal Medicine; Hospital Grad- 
uates' Club of Brooklyn (annual). 



Died. 

BoARDMAN. — In Boston Mass., on Tuesday, January 11th. 
Dr. William E. Boardman, aged seventy-six years. 

Caulkings. — In Hornell, N. Y., on Tuesday, January 
4th, Dr. Frank L. Caulkings, aged seventy-three years. 

De Lap. — In Gloucester, N, J., on Thursday, January 
6th, Dr. W. L. De Lap, aged sixty-eight years. 

FixLEY. — In Brooklyn, N. Y., on Wednesday, January 
Sth, Dr. Eugene Francis Finley, aged fifty-two years. 

Gordox. — In Los Angeles, Cal., on Wednesday, January 
Sth, Dr. J. S. Gordon, aged sixty-six years. 

Helme. — In Albany, N. Y., on Tuesday, January 4th, Dr. 
Thomas Helme, of McKownville, aged fifty-three years. 

Rowland. — In Cortland, N. Y., on Saturday, January 
1st. Dr. Frank P. Howland, aged eighty years. 

McFadden. — In Philadelphia, Pa., on Sunday, January 
9tli, Dr. William McFadden, aged seventy-six years. 

Murphy. — In Mobile, Ala., on Wednesday, January Sth, 
Dr. Thomas Charles Murphy, aged seventy-seven years. 

NoL.'VN. — In Philadelphia, Pa., on Wednesday, January 
Sth, Dr. Edward James Nolan, aged seventy-four years. 

O'Dea. — In Stapleton, S. I., on Wednesday, January 
12th, Dr. James J. O'Dea, aged eighty-four years. 

Rogers. — In Cascade, Wis., on Thursday, December 23rd, 
Dr. A. C. Rogers, aged seventy-seven years. 



Book Reviews 



\'i<:xi-:ki-:ai. 1)isi<:ase. 

Prevention of I'cnercal Disease. By Sir Archdall 
Reii). K. H. E.. M.B., F. R. S. E. With an Introductorv 
Chaptor l)y Sir Bryax Donkix, M. D, F. R. C. V. 

* 

It may be premised before entering into a con- 
sideration of this hook that the author knows well 
whereof he speaks. Sir Archdall Reid has had most 
favorable opportunities for investigating and study- 
ing venereal disease in all its phases and he is 
excellently qualified to take the best advantage of 
these opportunities. He is not only a scientific man 
of the hrst rank, but is endowed also with sound 
common sense, a quality not infrequently absent 
from men of science. As witness of this combina- 
tion of scientific and common sense, his book on 
alcoholism may be referred to as the most able pre- 
sentation of the subject ever given. 

His work at Portsmouth, the British naval port 
and a hot bed of venereal infection, has convinced 
him that venereal disease is easily prevented, that 
is, if proper and adequate preventive measures 
are applied early enough, and his war experience 
has taught him that such meastires are at hand and 
indeed have been already practised on a large scale 
in various parts f)f the world and always with suc- 
cess. He therefore gives as his emphatic opinion 
that the prevention of venereal disease is a certainty 
in the near future and that with official help it w'ill 
come quickly in Great Britain ; without such help 
more slowly btit come it will. He further states, 
what is obviously true, that it depends upon the 
diffusion of a little ,simple knowledge of a kind that 
spreads rapidly, and which once diffused is diffused 
forever. 

Conseqtiently, this book of Sir Archdall Reid 
should give it a start with the public and should 
aid in its diffusion immensely. Until the public is 
educated as to the real state of affairs with regard 
to venereal disease and the most effective means of 
prevention, it is hopeless to expect much progress 
in discussing the book. It shoitld be said at once, 
that it has been written mainly to propagate the 
views of the British Society for the I'revention of 
Venereal Disease but also that the author has be- 
come absolutely assured by a wide experience that 
these views are based on a firm foundation. These 
views are that reliable disinfectants shotdd be used 
as promptly as possible after intercourse, that their 
value is effective in proportion to the speed with 
which they are used after the need for them has 
arisen. According to Sir Archdall Reid, and his 
testimony is tmdoubtedly reliable, many doctors 
putting these principles into practice had reduced 
the venereal disease, previously rife among their 
charges, almost to the vanishing point. As the 
author says, "obviously there tnust be something 
peculiar in the methods that achieved success in the 
midst of ])revailing failure." 

The first cha])ter is taken up with impressing 
upon the reader the urgency of the venereal problem 
in Great Britain, '{'here is no time nor space here 
to dwell long upon this aspect of the subject. In the 
words of the author venereal diseases are the most 
prevalent by far of all the more serious diseases. 



There are few, if any, families of which some mem- 
bers have not been infected. Together they con- 
stitute a prolific, if not (juite the principal cause 
of poverty, insanity, ])aralysis, blindness, heart dis- 
ease, disfigurement, sterility, disablement and the 
life of pain to which many women are condemned. 
Our hospitals, asylums and homes for the broken 
are crowded with their victims. All this is true with 
respect to Great Britain and to all other countries 
to a greater or less extent. It must always be borne 
in mind that the venereal problem is an international 
one. 

The succeeding three chapters deal with the 
psychological phase of the problem which provide 
fascinating reading. Chapter IX in which Reid 
describes his "campaign against venereal diseases 
among troops in Portsmouth, who were all to a 
greater or lesser extent birds of passage, is of quite 
exceptional interest. The burden of this chapter 
is that Reid by precept and practice held on to the 
old saw that prevention is better than cure. "Dis- 
infect, at once, at once," was his constant refrain. 
As for the disinfectants to be used, it is stated that 
ordinary antiseptics are .NU])erior to calomel if (juick 
action be taken. 

A goodly part of tliis book is devoted to a criti- 
cism of the method of the British National Council 
for Combating Venereal Disease and to British 
official measures generally. The Council is averse- 
to what may be termed direct prophylaxis, de- 
claiming that the introduction of such a .scheme into 
a civilian population would be tantamount to af- 
fording opportunities for unrestrained vice. The 
main points in the book before us are that the public 
must be educated with respect to the venereal dis- 
eases and the best means of prevention and it is 
insisted that the most effective measures are dis- 
infection as soon as possible after intercourse. To 
.say that the book is well worth reading is faint 
praise, to say that it ought to be read by every adult 
would not be praising it too highly. Of course, 
there will be many at variance with the views ex- 
])ressed. 

However, it should not be forgotten that Reid 
has had a very wide practical experience with the 
tenets he advances. He can bring strong clinical 
evidence in sujiport of his contentions, which is 
after all the su])reme test. As the venereal question 
is international, it concerns America cjuite as much 
as it does Great Britain, and, therefore, a book the 
contents of which are founded upon the results of 
experience, shottld be welcomed and studied in this 
country. 

Unless direct prophylaxis is com])rehended and 
discussed by the medical profession and the public, 
no decision can be made on its merits and draw- 
backs. It may be the means of the salvation of the 
race or it may be found to be comparatively useless 
in civil life. In any event, it should be discussed and 
understood, and not tabooed as a subject not fit to 
speak of. Sir Archdall Reid's book presents the 
(|uestion from the ])oint of view of prompt prophy- 
laxis, with directness and lucidity greatly to be com- 
mended, and certainly is of great educational value. 



January 22, 1921.] 



BOOK REl-IEirS. 



167 



NEUROPSYCHIATRY. 

.Shell Shock and Other Nenropsychiatric Problems. Pre- 
sented in 589 Case Histories from the War Literature, 
1914-1918. By E. E. SouTii.ARn. M. D., Sc. D., Director 
(1917-1918) U. S. Army Neuropsychiatric Training 
School (Boston Unit) ; Late Major. Chemical Warfare 
Service, U. S. Army ; Bullard Professor of Neuropathol- 
ogy, Harvard Medical School ; Director, Massachusetts 
State Psychiatric Institute of the ^Massachusetts Com- 
mission on Mental Diseases. With a Bibliography by 
Norman Fenton. S. B., A. ^L; Sergeant, Medical Corps, 
U. S. Army (Assistant in Psychology to the Medical 
Director, Base Hospital 117, A. E. F.) ; Late Intern in 
Psychology, Psychopatliic Department, Boston State 
Hospital; Assistant in Keconstruction, National Commit- 
tee for Mental Hygiene. And an Introduction by Charles 
K. Mills, M. D., LL.D.. Emeritus Professor of Neu- 
rology, .University of Pennsvlvania. Illustrated. Bos- 
ton : W. M. Leonard, Vm. Pp. vi-98i. 

Southard's voluminous study of sliell shock forms 
in some respects an outstanding- work. He has 
spared no pains to glean his material from eminent 
neuropsychiatrists who dealt at hrst hand with the.se 
disorders arising during the war. There is not to 
be found, therefore. an\- other such abundant 
material in actual number of case histories. He has 
also set forth in an unprejudiced manner all the pos- 
sible symptoms that ])ecome manifest, with no 
attempt dogmatically to place them under one or 
another predetermined diagnosis. They are left for 
future study from the several points of view they 
suggest. 

For the writer is openminded enough to act 
upon the impression his researches make u]}on 
him. He becomes more firmly convinced of the 
wide range of possibilities in variety, in interre- 
lation, in sequence of cause and elYect, which may 
be subsumed under one such nonexplanatory term 
as shell shock. He even welcomes the term for 
its convenience to the lay mind, containing as it 
does just enough indication of more definite factors 
to turn attention to professional assistance. At 
the same time he believes that it has by the time of 
writing become a sufficiently denoting term to the 
neuropsychiatrist to remind him that it serves as a 
convenient cover for endless details of diagnosis 
and treatment extending in every direction. 

He presents a weiglit of evidence to show the 
necessity of delimiting and differentiating the phe- 
nomena appearing under it in order that syphilitic 
disorders, toxic psychoses, epilepsies, dementia 
prsecox, the cyclothymias, the psychoneuroses, shall 
not pass undiscovered. Phenomena pertaining to 
any of these at¥ections may already be present and 
must not be taken as direct result of shell shock. 
These affections may'^redispose to disturbance fol- 
lowing actual shock, or they themselves may be 
roused from latent to active form. All these facts 
create cjuestions of importance from the medical, 
the military, the legal point of view. 

Thus shell shock comes to be recognized as onlv 
a new term for an old state of things, a new pos- 
sibility arising under special conditions wherein all 
sorts of neuropsychopathic phenomena are possible. 
Under these new conditions much has been learned. 
Much more has presented itself as fertile material 
for further consideration. 

Southard lays stress upon the minute distinctidn 
which has arisen largely from Bahinski's work. 



between physiopathic and psychopathic di.sorders. 
He still fails to discern that close relationship be- 
tween the two, through unconscious i)sychic stimu- 
lation of pliysiological paths and reaction in turn of 
tlie physiological u])on the |)sychic. Tliere is also 
the same old imenlightening use of such terms as 
psychasthenia and the like, which cloaks the need 
for this deeper i)enet ration into d\iiamic factors. 
As a compendium of widely collected descriptive 
material otTered as a stinuihis to further study, the 
book remains as a monument of the indefatigable 
energy and the alert mind of one whom the pro- 
fession cannot forget. 

VACCINATION. 

/ 'itCi illation in the Tropics. By W. G. Kind. C. 1. E., Colonel, 
I. M. S. (Retired), Late Sanitary Commissioner with the 
(iovcrnment of Madras, and Superintendent (Jeiieral nf 
\ accination and Inspector General of Civil Hosi)itals in 
N'urina. Illustrated. London : Tropical Disease Kirreau. 
1920. Pp. vi-64. 

Inoculation, vaccination, smallpox, terms which 
everyone thought they knew all about, are only the 
doors to dee]i studies of bow they variously affect 
men of different races, how they are aft'ected by 
climate, the .safest methods of getting and conserv- 
ing good strains of vaccine and the periodicity of 
epidemics, all of which study advances us a long- 
way since the days of 1902 w'ben French doctors 
held vaccination parties and. with twenty or thirty 
ladies assembled, walked around inoculating on 
un.sterilized legs with an unsterilized instrument. 

What complete mastery of all these aspects of 
vaccination means, what conscientious research 
involves, can he learned through W. ii. King's 
book, written at the request of \^iscount Milner, 
Secretary of State for the English Colonies, for 
distrihution to the govemments of the tropical 
African dependencies. He first deals with the sul)- 
ject from a point of view which will rouse all men 
— that is, the money loss caused by an epidemic. 

One difficulty about the animal vaccine in tropical 
climates is that tl-ie exaggerated conditions of 
heat and alternate dry and moisture saturated 
atniospheric stales demand close supervision by 
responsible men giving their whole time : otherwise, 
successful cultivation of vaccine ^will he ho])eless. 
Suitable vaccine stations, food and quiet for the 
animals, great care in transmission, are all neces- 
sary. The influence of diet on the nature of vesicle 
])roduction is also very great. The staff should be 
well chosen, the .selection of calves most careful, 
fust as the veterinarians have found neurasthenic 
cows which needed a rest cure, so cheerful sur- 
roundings are necessary for the anteiiioculated 
calves, who are very susceptible to rougli treatment, 
even loud voices. 

The rejuvenation section shows the various 
methods compared, and the factors in degeneration. 
Tile ]ireservation of animal vaccine presents diffi- 
culties that no doctor in the temperate zone can 
'luite ajipreciale. The inclusion of Xoguclii's 
method of purification of vaccine is a valuable 
adjunct to the clearly put statements in this book 
and tlie whole will be welcomed by the medical 
-enlrio in opposing ihe advancement of the dreadful 
(lisea>c. 



168 



BOOK REVIEWS. 



[New V')rk 

MeDICAI, JOIRX.VL. 



MILITARY SPYING. 

The Secret Corps. A Tale of Intelligence on All Fronts. 
By Captain Ferdinand Tuohy. New York : Thomas 
Seltzer, 1920. Pp. 289. 

Spying and spy catching seemed a cotnparatively 
simple matter in ancient times, but today science aids 
both catclier and spy, and has created a hundred 
ways of detection and escape which keep the in- 
telligence departments of all nations unceasingly 
on the alert. Away back we see Judith, "beautiful 
in her countenance and witty in her words," calmly 
going into the enemy's camp to beguile Holofernes, 
and Joshua, falling a prey to the pretended ambas- 
sadors who "came with old wine bottles, old and 
rent and bound up ; with old shoes and clouted upon 
their feet, and old garments, and the bread of their 
provision dry and mouldy, saying, 'we be come 
from a far country,' " whereas the rogues dwelt 
quite near. The Hague law of those days must 
have been compelling, for Joshua, having passed his 
word to save them, simply detained them as hewers 
of wood and drawers of water for the temple. 

Of course, during the war it came to be a case 
of being suspected of being suspected, even as hun- 
dreds were executed during the French Revolution 
for unintentionally doing slightly abnormal things. 
This book will evoke gratitude and admiration for 
its revelation of the espionage work done, and our 
consequent safety. It would have been curious if, 
for one hour, the whole mechanism, crossing, run- 
ning parallel, submarine, miles high, winged, vocal, 
written, signalled, could have stood out in relief, to 
let us see the marvelous ingenuity displayed and 
the risks run. 

It is well pointed out how much power a queen 
has. Even a foolish princess on the throne of a 
foreign country is an agent who has access to 
cabinet documents, and to cabinet councils ; who 
can send the secrets of state to the land of her 
fathers. In the late war, German or Austrian 
women were on the thrones of Russia, Greece, 
Sweden, Spain (Queen Mother), Rumania (Car- 
men Sylva), and Bulgaria, while a German prince 
consort ruled in Holland. 

The Grecian queen, Sophia Dorothea, surrounded 
herself with German women, kept Greece out of 
war, and established a complete espionage bureau 
behind the lines at Salonika, even through the lines. 
The story of court intrigue at Athens is one of 
the most amazing pictures of the whole war. It 
was intrigue, corruption, and seduction in their most 
outrageous forms. 

The spy organizations had to be divided up into 
zones, obviously necessary, if we consider even one 
zone — the British, in France and Flanders with an 
abnormal population due to many hundred thousand 
refugees, Flemish, French, and Belgian, and added 
to these three or four million regular inhabitants, 
the British spy zone meant 800 communes, each 
covering about five miles. The book abounds 
with the unexpected. Once the truth was some- 
times so obviously the truth that the Germans, 
intercepting the message, concluded it was not the 
truth or it would not have been sent, which was 
exactly what the English thought they would do. 
Again, on the second day of Loos, train after 



train steamed up the German lines, twenty-five of 
them, each train holding 800 men. The English 
plans were remolded. It was faked "raihvay 
activity" for the trains were empty! Two years 
later, General Byng's November battle for Cambrai, 
there was great enemy activity, hundreds upon 
hundreds of lorries quite observable. Clearly the 
enemy was being moved into a new reserve. 
Headquarters was rung up. "Carry on," came the 
answer. "They played this trick before. The lor- 
ries are empty." 
They were not ! 

The book keeps one all alert. A continued read- 
ing will make a man involuntarily get up frotn his 
chair very cautiously and cast a suspicious eye even 
on his intimate associates and surroundings until 
he remembers the world is at peace ! 

POTTERISM. 

Potterism. By Rose Mac^ulay. New York : Boni & Live- 
right, 1920. Pp. x-227. 

Unconsciously the reader gathers in the opening 
pages what Potterism is, but is rather relieved to 
get a clear definition from the author on page 66 : 

"Potterism has, for one of its surest bases, fear. 
The other bases are ignorance, vulgarity, mental 
laziness, sentimentality and greed. The ignorance 
which does not know facts, the vulgarity which 
cannot appreciate values ; the laziness which will not 
try to learn either of those things ; the sentimentality 
which, knowing neither, is stirred by the valueless 
and the untrue ; the greed which grabs and exploits ; 
the fear of public opinion, the fear of scandal, the 
fear of independent thought, of loss of position, of 
discomfort, of consequences, of truth." 

There are only two characters who are untainted 
by Potterism — Arthur Gideon, of Jewish extrac- 
tion, editor of The Fact, and Katherine Varick, an 
Oxford girl enjoying a chemical research scholar- 
ship. So, saving these two, the world of this hook is 
made up of the Potter twins, Jane and Johnnie, who 
professedly hate Potterism but stealthily, even 
openly, enjoy its fruits, Papa and Mama and Clare 
Potter, a newspaper magnate, an author, and a 
nonentity, their clergyman son, Frank, Hobart, 
editor of a Potter paper, and Jake, a youfig West 
End vicar of "moderately aristocratic lineage" but 
antipotterist. 

There is no subtle persuasion against Potterism 
woven into the story. The characters are drawn in 
a subcynical, sagacious, humorous fashion, which 
amuse, but makes readers flinch a little. They seem 
to be getting too intimate a view of their friends. 
It would have been well if a deeper discernment of 
all that is noble and true had been joined to the 
writer's keen insight into human nature and touched 
her strong desire for truth. In describing Gideon 
after he has (supposedly) knocked Hobart down- 
stairs and killed him, she voices the old surprised 
inquiry as to whether the good man can suddenly 
or deliberately walk in miry ways, whether the low- 
minded and repulsive man can produce valor and 
virtue from the empty pockets of his shabby, filthy 
garments, for many disbelieve this, despite the 
annals of asylum and prison. If Rose Macaulay 
can draw such clever realistic pictures of men as 



January 22, 1921.] 



BOOK REVIEWS. 



169 



tlie)- are, it is a safe prediction to say her next work 
will contain a few men as they might be, just to 
tempt our dusty souls into more breezy, sunlit ways. 

Some little, well, not errors, but ungraceful 
expressing, will not appear in her second book, e. g. : 
. . . one doesn't know enough ; one hasn't learnt 
or lived enough to be first hand ; and one lacks 
selfconfidence. But by five or six and twenty 
one should have left that behind. One should know 
what one tliinks, and what one means. . . . 

"A woman can be a man's friend all their lives, 
but a man, in nine cases out of ten, will either get 
tired of it or want more." 

There was no weekly which caused Edward VII 
to chuckle more heartily than Modern Society, a 
paper which consistently attacked the rich, routed 
out all scandals in high life, and referred to Queen 
\'ictoria as Mrs. Little Britain and the Heir as 
"Bertie," and it is just possible that smug Potter- 
ites, w'ho live in words not deeds, and are yet not 
too selfsatisfied, will enjoy and profit from tliis 
book. Nearly everyone will be glad to have a name 
given to the selfdeception whicli blindly applauds 
that which it uneasily condemns, unconsciously 
echoing the wish : 

. . . . that there might in England be 

A duty on Hypocrisy, 

A tax on humbug, an excise 

On solemn plausibilities. 

<^ 

New Publications Received. 



\We publish full lists of books received, but we acknowl- 
edge no obligation to review them all. Nevertheless, so 
far as space permits, we review those in which we think 
our readers are likely to be interested.] 



SAN CRISTOBAL DE LA HABANA. By JoSEPH HeRGESHEIMER. 

New York : Alfred A. Knopf, 1920. Pp. 255. 

TWENTV-SEVEXTH .^XXUAL REPORT OF THE MAX.\GERS .AND 

OFFICERS OF THE CR.\iG COLONY. Craig Colony Press, 1920. 
Pp. 84. 

THE devil's paw. Bv E. Phillips Oppenheim. With 
Frontispiece by H. Weston Taylor. Boston : Little, Brown 
& Co., 1920. Pp. 295. 

THE privilege OF PAIN. By Mrs. Leo Everett. Intro- 
duction by Kate Douglass Wiggin. Boston : Small, May- 
nard & Co., 1920. Pp. 105. 

the spoils of the strong. By Ele.\nor T.\lbot Kin- 
kead (Mrs. Thompson Short). New York: The James A. 
McCann Company, 1920. Pp. 308. 

THE human atmosphere. By Walter J. Kilner, B. A., 
M. B. (Cantab.), M. R. C. P., etc., Late Electrician to St. 
Thomas's Hospital, London. With Sixty-four Illustrations. 
London : Kegan Paul, Trench, Trubner & Co., Ltd., 1920, 
and New York : E. P. Button & Co., 1920. Pp. vii-300. 

AIDS TO osteology. By Phiup Turner, B. Sc., M. B., 
M.S. (Lond.), F. R. C. S., Assistant Surgeon, Guy's Hos- 
pital ; Teacher of Operative Surgery in the Medical School. 
Second Edition. New York: William Wood & Co., 1920. 
Pp. 187. 

DREAM psychology. Psychoanalysis for Beginners. 
By Prof. Dr. Sigmund Freud. Authorized English Trans- 
lation by M. D. Eder. With an Introduction by Andre 
Tridon, Author of Psychoanalysis, Its History, Theory, 
and Practice, Psychoanalysis and Behaznor, and Psycho- 
analysts, Sleep, and Dreams. New York: The James A. 
McCann Company, 1920. Pp. xi-237. 



ANNUAL report OF THE SURGEON GENERAL, U. S. NAVY, 

Chief of the Bureau of Medicine and Surgery, to the Sec- 
retary of the Navy for the Fiscal Year 1920. Wash- 
ington: Government Printing Office, 1920. Pp. 326. 

collected papers of the mayo clinic, ROCHESTER, MIN- 
NESOTA. Edited by Mrs. M. H. Mellish. Volume XI, 1919. 
Published September, 1920. Philadelphia and London : 
W. B. Saunders Company, 1920. Pp. 1331. 

SLEEP WALKING AND MOON WALKING. .\ Mcdicoliterary 
Study. By Dr. J. Sadger, Vienna. Translated by Louise 
Brink. Nervous and Mental Disease Monograph Scries 
No. 31. New York and Washington: Nervous and Mental 
Disease Publishing Company, 1920. Pp. x-140. 

THE SOCIAL DISEASES. Tubcfculosis, Syphilis, Alcoholism, 
Sterility. By Dr. J. Hericourt. Translated, and With a 
Final Chapter, by Bernard Miall. London: George Rout- 
ledge & Sons, Ltd.; New York: E. P. Dutton & Co., 1920. 
Pp. viii-246. 

PARACELSUS. His Personality and Influence as Physician, 
Chemist and Reformer. By John Ma.xson Stillman, 
Professor of Chemistry Emeritus, Stanford University. 
Chicago and London : The Open Court Publishing Com- 
pany. 1920. Pp. viii-184. 

anesthetics. Their Uses and Administration. By 
Dudley Wilmot Buxton, M.D., B.S., Member of the 
Royal College of Physicians; Sometime President of the 
Society of Anaesthetists ; Member of University College, 
etc. Sixth Edition. Philadelphia : P. Blakiston's Son & 
Company, 1920. Pp. xvi-548. 

THE MAJOR symptoms OF HYSTERIA. Fifteen Lcctures 
given in the Medical School of Harvard University. By 
Pierre Janet, Ph.D., M.D., Member of the Institute of 
France, Professor of Psychology in the College de France. 
Second Edition with New Matter. New York : The Mac- 
millan Company, 1920. Pp. xxiii-34S. 

medical GYMNASTICS IN MEDICINE AND SURGERY. By E. 

Bellis Clayton, M. B., B.C. (Cantab.), Director of the 
Physiotherapeutic Department, and in Charge of the Mas- 
sage and Electrical School, King's College Hospital, 
London. New York : Longmans, Green & Co. ; London : 
Edward Arnold, 1920. Pp. viii-159. 

A NATURALIST ON LAKE VICTORIA. With an AcCOUnt of 

Sleeping Sickness and the Tse-Tse Fly. By G. D. Hale 
Carpenter, D. M., B. Ch. (Oxon.) Uganda Medical Ser- 
vice ; Fellow of the Linnaen, Entomological, and Zoological 
Societies of London. With Two Colored Plates, a Map, 
Charts, and Eighty-seven Illustrations. New York : E. P. 
Dutton & Co., 1920. Pp. xxiv-333. 

INTRODUCTION TO GENERAL CHEMISTRY. An Exposition of 
the Principles of Modern Chemistry. By H. Copaux, 
Professor of Mineral Chemistry at the School of Industrial 
Physics and Chemistry of the City of Paris. Translated by 
Henry Leffmann, A. M., M. D., Member of the American 
Chemical Society and of the (British) Society of Public 
Analyses. With Thirty Illustrations. Philadelphia : P. 
Blakiston's Son & Co., 1920. Pp. x-195. 

THE PRACTICAL MEDICINE SERIES. Comprising Eight Vol- 
umes on the Year's Progress in Medicine and Surgery. 
Under the General Editorial Charge of Charles L. Mix, 
A. M., M. D., Professor of Physical Diagnosis in the 
Northwestern University Medical School Volume III : 
The Eye, Ear, Nose, and Throat. Edited by Casey A. 
Wood, C. M., M. D., D. C. L. ; Albert H. Andrews, M. D., 
and George E. Shambaugh, M. D. Series 1920. Chicago: 
The Year Book Publishers, 1920. Pp. 381. 

THE PRACTICAL MEDICINE SERIES. Comprising Eight Vol- 
umes on the Year's Progress in Medicine and Surgery. 
Under the General Editorial Charge of Charles L. Mix, 
A. M., M. D., Professor of Physical Diagnosis in the 
Northwestern University Medical School. Volume II :' 
General Surgery. Edited by .\lbert J. Ochsner, M. D., 
F. R. M. S., LL. D., F. A. C. S., Major, M. R. C, U. S. Army ; 
Surgeon in Chief, Augustana and St. Mary's of Nazareth 
Hospitals ; Professor of Surgery in the ^ledical Depart- 
ment of the State University of Illinois. Series 1920. 
Chicago : The Year Book Publishers, 1920. Pp. 620. 



Practical Therapeutics and Preventive Medicine 

A Compendium of Treatment and Prophylaxis, Original and Adapted 



Pernicious Anemia. — James G. Carr {American 
Journal of the Medical Sciences, Xovember, 1920). 
in a study of 148 cases, finds thai the clinical com- 
plex known as pernicious anemia presents certain 
characteristic blood findings, particularly the